Just two months after being charged, all 11 defendants implicated in the $300 million Spectrum/Reliable healthcare fraud have pleaded guilty, announced U.S. Attorney for the Northern District of Texas Chad E. Meacham.

Ten defendants, including two medical doctors, were indicted February 9. An eleventh defendant was charged on March 16.

Six of the original ten defendants – Laredo-based internal medicine doctor Eduardo Canova, family medicine doctor Jose Maldonado, nurse practitioner Keith Wichinski, Reliable Labs cofounder Abraham Phillips, marketing firm owner Juan David Rojas, and marketing employee Laura Ortiz – filed plea papers on February 11, just two days after being indicted. The final defendant – Reliable Labs cofounder Biby Kurian – filed plea papers on April 6 and entered her plea on April 13.

“The swift resolution of this case is a testament to both our office and to the investigative agencies that worked diligently to ensure our case was airtight,” said U.S. Attorney Chad Meacham. “We cannot allow physicians’ judgement to be clouded by financial considerations.”

“This proactive investigation identified an illegal kickback conspiracy that resulted in substantial evidence and a guilty plea from each defendant,” said Dallas FBI Special Agent in Charge Matthew J. DeSarno. “I commend our partners and the Northern District of Texas for their meticulous work in unraveling the schemes perpetrated by these defendants, and for their work to protect American taxpayers and the integrity of our healthcare system.”

According to court documents, the founders of several lab companies, including Unified Laboratory Services, Spectrum Diagnostic Laboratory, and Reliable Labs LLC, paid kickbacks to induce medical professionals to order medically unnecessary lab tests, which they then billed to Medicare and other federal healthcare programs.

The medical professionals -- including Dr. Canova, Dr. Maldonado, and Mr. Wichinski – accepted the bribes and ordered millions of dollars’ worth of tests.

Meanwhile, Unified, Spectrum, and Reliable disguised the kickbacks as legitimate business transactions, including as medical advisor agreement payments, salary offsets, lease payments, and marketing commissions.

The labs, through marketers, paid doctors hundreds of thousands of dollars for “advisory services” which were never performed in return for lab test referrals. They also paid portions of the doctors’ staff’s salaries and a portion of their office leases, contingent on the number of lab tests they referred each month. In some instances, lab marketers even made direct payments to the provider’s spouse. (When the labs threatened one provider that payments would cease if he didn’t refer more tests, he immediately increased his lab referrals, averaging approximately 20 to 30 referrals per day.)

Knowing they could disguise additional kickbacks using a provider-ownership model, the founder of Spectrum and Unified, Jeffrey Madison, convinced the co-founders of Reliable to convert Reliable into a physician-owned lab. Reliable offered physicians ownership opportunities only if those physicians referred an adequate number of lab tests. In some cases, they made advance disbursement payment to physicians in an effort to appease the physician and ensure he would not send samples to other labs.

As a result of these kickbacks, laboratories controlled by the defendants were able to submit more than $300 million in billing to federal government healthcare programs.

In plea papers, Dr. Maldonado admitted he received more than $400,000 in kickbacks for ordering more than $4 million worth of lab tests; Dr. Canova admitted he received more than $300,000 in kickbacks for ordering more than $12 million worth of lab tests.

Defendants’ pleas are as follows:

• Jeffrey Paul Madison, founder of Unified Laboratory Services and Spectrum Diagnostic Laboratory – conspiracy to pay and receive healthcare kickbacks and a substantive count of paying and receiving healthcare kickbacks (two counts)

• Mark Christopher Boggess, chief operating officer for Spectrum and Unified – misprison (concealment) of a felony

• Biby Ancy Kurian, co-founder of Reliable Labs, LLC – conspiracy to pay kickbacks

• Abraham Phillips, co-founder of Reliable Labs, LLC – conspiracy to pay kickbacks

• Dr. Jose Roel Maldonado, family medicine doctor based in Laredo – conspiracy to solicit and receive illegal kickbacks

• Dr. Eduardo Carlos Canova, internal medicine specialist based in Laredo – conspiracy to solicit and receive illegal kickbacks

• Keith Allen Wichinski, board-certified nurse practitioner based in San Antonio – conspiracy to solicit or receive kickbacks

• David Michael Lizcano, owner of DCLH, a marketing firm engaged by Unified, Spectrum, and Reliable – conspiracy to pay and receive healthcare kickbacks and a substantive count of paying and receiving healthcare kickbacks (two counts)

• Laura Ortiz, sister of David Lizcano and employee at his marketing firm – conspiracy to pay and receive healthcare kickbacks

• Juan David Rojas, owner of Rojas & Associates, another marketing firm engaged by Unified, Spectrum, and Reliable – conspiracy to pay and receive healthcare kickbacks

• Sherman Kennerson, investor in Unified (charged via criminal information) – conspiracy to pay kickbacks

Under the applicable statutes, Mr. Madison and Mr. Lizcano face up to 15 years each in federal prison. Mr. Kennerson, Ms. Ortiz, Mr. Phillips, Ms. Kurian, Dr. Maldonado, Dr. Canova, Mr. Wichinski, and Mr. Rojas face up to five years; Mr. Boggess faces up to three years.

“The expeditious resolution of this matter is a testament to the thorough investigation and valuable collaboration between investigative partners and prosecutors,” said Miranda L. Bennett, Special Agent in Charge for the Office of Inspector General of the U.S. Health and Human Services. “We will continue working with our partners to protect federal health care programs and the beneficiaries who depend on these programs for treatment and care.”

“As the investigative arm of the DoD Office of Inspector General, the Defense Criminal Investigative Service (DCIS) and our colleagues work hard to hold accountable those who undermine Federal health care programs such as TRICARE, “said Acting Special Agent in Charge Gregory P. Shilling of the DCIS Southwest Field Office. "Safeguarding TRICARE not only protects our warfighters, their families, and retirees, but it also preserves valuable taxpayer resources."

The Federal Bureau of Investigation’s Dallas Field Office – Fort Worth Resident Agency conducted the investigation with the assistance of the U.S. Department of Health and Human Services’ Office of Investigations, the Defense Criminal Investigative Service (DCIS), and the Veterans Affairs’ Office of Inspector General. Assistant U.S. Attorney P.J. Meitl is prosecuting the case.

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HAMMOND- Justyn Arch, age 34, and Trystan Arch, age 31 both of Valparaiso, Indiana were charged with healthcare fraud by way of a single count Grand Jury Indictment which was unsealed today, announced Acting U.S. Attorney Gary T. Bell.

According to documents in this case, Arch Complete Family Dentistry, with offices located in Chesterton, Crown Point, and briefly in Knox, Indiana, was an authorized Indiana Medicaid provider of dental procedures. In October 2017, Justyn Arch, Vice President of Arch Complete Family Dentistry, also managed the Crown Point office. Trystan Arch managed the Chesterton office.

The Indictment alleges that Justyn and Trystan Arch executed a scheme to defraud Indiana Medicaid by causing false and fictitious entries in patient files. The false entries showed that Arch dentists performed dental surgery when in fact no surgery had been performed. The claims totaled more than $350,000 in false and fictitious claims to Indiana Medicaid.

The United States Attorney’s Office emphasizes that an Indictment is merely an allegation and that all persons are presumed innocent until, and unless proven guilty in court.

If convicted, any specific sentence to be imposed will be determined by the Judge after a consideration of federal statutes and the Federal Sentencing Guidelines.

This case is a result of an investigation by the Federal Bureau of Investigation, Indiana Attorney General’s Office Medicaid Fraud Control Unit, Internal Revenue Service-Criminal Investigation Division and U.S. Department of Health and Human Services with the assistance of the Porter County Prosecutor’s Office. This case is being prosecuted by Assistant United States Attorney Philip C. Benson.

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A federal grand jury in the Western District of Arkansas returned an indictment yesterday charging an Arkansas man who owned or managed numerous diagnostic testing laboratories with health care fraud in connection with over $100 million dollars in false billings for urine drug testing, COVID-19 testing, and other clinical laboratory services.

According to court documents, Billy Joe Taylor, 42, of Lavaca, engaged in a scheme between February 2017 and May 2021 in connection with diagnostic laboratory testing, including urine drug testing and tests for respiratory illnesses during the COVID-19 pandemic, that were medically unnecessary, not ordered by medical providers, and/or not provided as represented. According to the indictment, Taylor controlled and directed multiple diagnostic laboratories, and used those labs to submit more than $100 million in false and fraudulent claims to Medicare. The indictment alleges that Taylor obtained medical information and private personal information for Medicare beneficiaries, and then misused that confidential information to repeatedly submit claims to Medicare for diagnostic tests that were not ordered by medical providers and were not actually performed by the laboratories. Taylor allegedly then used the proceeds of the fraud to live a lavish lifestyle, including purchasing numerous luxury automobiles, including a Rolls Royce Wraith, as well as real estate, jewelry, guitars, and other luxury clothing and items.

Taylor is charged with 16 counts of health care fraud, and one count of engaging in a monetary transaction in criminally-derived property. Taylor was previously charged by criminal complaint in May 2021. The defendant is scheduled for his arraignment on Nov. 23 before U.S. Magistrate Judge Mark E. Ford of the U.S. District Court for the Western District of Arkansas. Each of the counts is punishable by a maximum penalty of 10 years in prison. A federal district court judge will determine any sentence after considering the U.S. Sentencing Guidelines and other statutory factors.

Assistant Attorney General Kenneth A. Polite Jr. of the Justice Department’s Criminal Division; Acting U.S. Attorney David Clay Fowlkes for the Western District of Arkansas; Special Agent in Charge James A. Dawson, of the FBI’s Little Rock division; Special Agent in Charge Miranda Bennett of the Department of Health and Human Services-Office of Inspector General (HHS-OIG), Dallas Regional Office; and Special Agent in Charge Christopher Altemus of the IRS-Criminal Investigation, Dallas Field Office, made the announcement.

The FBI, HHS-OIG, and IRS-Criminal Investigation are investigating the case.

Senior Litigation Counsel Jim Hayes and Trial Attorney D. Keith Clouser of the Criminal Division’s Fraud Section’s National Rapid Response Strike Force and Assistant U.S. Attorney Kenneth Elser of the U.S. Attorney’s Office for the Western District of Arkansas are prosecuting the case.

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LUBBOCK, Texas (KCBD) - Tonight we are hearing from Lubbock Congressman Jodey Arrington about why he voted against a bill to expand health care benefits for Veterans.

He joined nearly the entire Republican Party in voting against the bill.

The bill would provide presumptive health care benefits to Veterans who served around “burn pits.”

Those were fields of trash and debris burned in the middle east as far back as the Gulf War and throughout the entire “global war on terror.”

The PACT Act would presume certain disabilities and health issues after a Veteran’s service are connected to that exposure.

Congressman Arrington says he supports the idea, but the proposal is too expensive, and would create a backlog at the VA.

Here’s the statement the congressman sent exclusively to KCBD:

“We have a moral obligation to provide assistance to Veterans affected by burn pits, which is why I voted for H.R. 6659, the Health Care for Burn Pit Veterans Act, a responsible and effective way to solve this serious problem. Unfortunately, Democrats - once again - jammed through the partisan PACT, which would waste billions of taxpayer dollars and worsen Veterans’ access to care by tripling the disability claims backlog for Veterans. West Texans expect their tax dollars to be spent on solving problems, not creating bigger ones.”

The bill Congressman Arrington supports does not presume any Veterans’ health care problems are directly tied to burn pit exposure.

Instead, it includes a year of open enrollment, and evaluations for coverage.

The congressman’s office tells us that bill would be cheaper and include fewer Veterans, so there would be less of a backlog.

The bill passed the senate unanimously, but does not have a date in the House.

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With cost imperiling a $282 billion bill that would help those exposed to burn pits, as well as Vietnam Veterans with hypertension, two senators are proposing a much less expensive compromise that could still help more than 1 million Veterans get Department of Veterans Affairs health care.

Committee Chairman Sen. Jon Tester, D-Mont., and Kansas Sen. Jerry Moran, the committee's ranking Republican, introduced a bill Tuesday that would create a one-year enrollment period for VA medical care for post-9/11 combat Veterans who served after 1998 and never enrolled. It would also extend the enrollment period for all formerly deployed post-9/11 combat Vets from five years to 10.

The bill, called the Health Care for Burn Pit Veterans Act, would allow Veterans discharged after Sept. 11, 2001, to qualify. The senators peg the cost at less than $1 billion.

But advocates are outraged over what they see as a breakdown of major legislative initiatives, estimated to cost hundreds of billions of dollars, that would help former service members or their survivors -- the Honoring Our Promise to Address Comprehensive Toxics, or PACT, Act, and the Comprehensive and Overdue Support for Troops, or COST of War Act -- since Tester and Moran's bill doesn't include disability compensation or a list of illnesses presumed to be related to exposure eligible for expedited benefits.

"How does the expansion of health care help the survivors filing for death benefits?" tweeted Rosie Torres, co-founder of the nonprofit Burn Pits 360 group. "Stop the delay and deny! Grant presumption!"

"Putting a band aid on a open sucking chest wound with your bulls--- legislation," tweeted activist John Feal. "These men and [women] need better, deserve better, earned better and you failed them! I will dedicate my life to ensure you fail again!"

The senators said the legislation would expand VA health care to at least 1 million of the 3.5 million Veterans who served and were exposed to burn pits and other types of pollution while deployed but don't have access to VA care.

"As more and more Veterans report alarming rates of toxic exposure-related illnesses, one thing is abundantly clear: Without action, post-9/11 Veterans will suffer as Vietnam Veterans have," Tester said during a press conference at the U.S. Capitol on Tuesday.

"This is the first step on a continuum of trying to make certain that those who experienced toxic exposure and, as a result, are suffering in their health and well-being, receive medical benefits," Moran said.

The new proposal comes as the House of Representatives is poised to debate the $282 billion legislative package that would expand health care and provide disability compensation to millions of Veterans, including Vietnam Vets with hypertension and anyone who has served since 1990 in the Persian Gulf region and elsewhere and has exposure-related illnesses.

Tester has introduced a similar $223 billion bill that has been approved by the Veterans Committee but has yet to be considered by the full Senate.

Both proposals have received pushback from legislators about their cost.

Tester and Moran's bill would be the first step in a three-pronged approach to providing Veterans with care and benefits, according to the senators.

"The goal here is to get this done by the end of this Congress," Tester said.

"It's the kind of legislation that would be able to be supported in a bipartisan way and signed by the president," Moran said of the new proposal.

The lawmakers said the latest proposal is supported by the largest Veterans service organizations, including the American Legion and Veterans of Foreign Wars, along with Disabled American Veterans, Wounded Warrior Project, and Iraq and Afghanistan Veterans of America.

According to the senators, the next step in expanding benefits to affected Veterans would be to ensure that the VA is establishing illnesses that are considered service-connected in a transparent way, followed by providing benefits to ill Veterans who have been "long ignored or forgotten."

Moran noted that the VA has been making progress on establishing illnesses presumed related to exposure to burn pits, beginning last year when it named three conditions -- rhinitis, asthma and sinusitis -- as related and eligible for expedited benefits.

"The Department of Veterans Affairs has the authority, legal authority, to deal with presumptions, and they are in the process of doing so," Moran said. "They have a pilot program to determine how best to utilize the authorities they have in regard to presumptions."

The VA also is reviewing data and research to determine whether some types of cancer and a rare lung disease, known as constrictive bronchiolitis, should be added to the list of presumptive illnesses. Decisions on these conditions are expected this year.

In addition to expanding VA health care eligibility, the proposal would require the department to provide screenings for toxic exposure during medical appointments; increase education and training requirements for VA health care and benefits personnel on toxic exposures; and require the department to reach out to Veterans on exposures and related VA care and benefits.

The bill also would increase federal research on toxic exposures.

Moran said he expects the bill to pass the Senate Veterans Affairs Committee on Wednesday and be considered by the full chamber shortly.

He also anticipated that a similar bill would be proposed in the House.

"Certainly, there's no question but we're going to work with the House," Moran said. "We are taking our first step, our step of three, and we're guessing the legislation is going to pass Congress."

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Las Vegas, NV – Today, Nevada Attorney General Aaron D. Ford announced that April Lynn Brown, 47, of Las Vegas, and Dynamic Minds Family Services, LLC (Dynamic Minds), were sentenced in a Medicaid fraud case involving billing for services that were not provided to Medicaid recipients. The fraud occurred between January 2017 and May 2018.

Eighth Judicial District Court Judge Ronald J. Israel sentenced April Lynn Brown and Dynamic Minds for a category “D” felony offense of Submitting False Claims, Medicaid Fraud. Judge Israel sentenced Brown to 12 to 24 months in prison, suspended, and placed her on probation for two years. As part of the sentence, Dynamic Minds was also ordered to pay $499,848 in restitution, and Brown was ordered to perform 150 hours of community service. Persons convicted of Medicaid fraud may also be administratively excluded from future Medicaid and Medicare participation.

“Overbilling and false billing of Medicaid hurts taxpayers and puts this important healthcare program at risk,” said AG Ford. “My office will hold healthcare providers accountable when they don’t conduct business honestly with Nevada’s healthcare programs.”

The investigation of this case began after the Attorney General’s Medicaid Fraud Control Unit (MFCU) received information that April Lynn Brown, a licensed Qualified Mental Health Professional and owner of Dynamic Minds, had billed Nevada Medicaid for excessive Rehabilitative Mental Health (RMH) services. The investigation revealed that Dynamic Minds, through Brown as its owner and service provider, submitted claims to Nevada Medicaid purporting to have provided in excess of 24 hours of RMH services each day over a period of several months. In fact, Brown had neither provided nor could have provided the services in such quantities.    

The MFCU investigates and prosecutes financial fraud by those providing healthcare services or goods to Medicaid patients. The MFCU also investigates and prosecutes instances of elder abuse or neglect. The Nevada MFCU receives 75 percent of its funding from the U.S. Department of Health and Human Services under a grant award. The remaining 25 percent is funded by the State of Nevada, MFCU. Anyone wishing to report suspicions regarding any of these concerns may contact the MFCU at 702-486-3420 or 775-684-1100.

This case was investigated by the Attorney General’s Medicaid Fraud Control Unit and prosecuted by Senior Deputy Attorney General Steve Sidhu.

To view the criminal information of April Lynn Brown, click here. To view the criminal information of Dynamic Minds Family Service, LLC, click here.

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The Medicare Fraud Strike Force (“MFSF”) is part of a joint initiative between the U.S. Department of Justice, U.S. Department of Health and Human Services and state Medicaid Fraud Control Units to reduce and prevent Medicare and Medicaid fraud through enhanced interagency cooperation. Its purpose is to focus on the worse offenders in fraud, in the highest intensity regions, using data analysis techniques to identify abnormal billing levels in health care fraud “hot spots,” i.e., cities with unusually high levels of billing and other fraud. The U.S. Department of Justice currently maintains 15 strike forces operations in 24 federal districts and has charged more than 4,600 defendants who have collectively billed federal health care programs and private insurers for approximately $23 billion. In addition, the HHS Centers for Medicare and Medicaid Services, working in conjunction with the HHS-OIG, are taking steps to increase accountability and decrease the presence of fraudulent providers.

As part of the recent National Enforcement Action, Acting United States Attorney Ellison C. Travis announced new charges against two individuals for health care related crimes in Baton Rouge. On September 9, 2021, a federal grand jury returned a seven-count indictment charging Terry Steven Wilks, Jr., age 39, of Greenwell Springs, Louisiana, and Leslie Amanda McHugh, age 36, of Riverview, Florida, with conspiracy to defraud the United States and to pay and receive kickbacks, offering and paying kickbacks, and soliciting and receiving kickbacks.

According to the indictment, Wilks was the owner of Acadian Diagnostic Laboratories, LLC, a clinical laboratory based in Baton Rouge that provided diagnostic testing services, including urine drug testing. Acadian was enrolled as a Medicare and a TRICARE provider. McHugh was formerly a registered nurse licensed in the State of Florida. The indictment alleges that in 2015, the Florida Board of Nursing revoked McHugh’s nursing license, and in 2016, Medicare excluded her from participation in all federal health care programs. According to the indictment, despite her exclusion and subsequent purported termination from Acadian, Wilks continued to pay McHugh to refer doctors’ orders and specimens to Acadian for urine drug testing in exchange for kickback payments. These payments were allegedly made in cash, as well as funneled through a company created by Wilks. The indictment alleges that from August 2017 to April 2018, Wilks and McHugh caused Acadian to submit approximately $549,580 in claims to Medicare and $17,612 in claims to TRICARE for laboratory testing services that were referred by McHugh in exchange for kickback payments.

Acting U.S. Attorney Ellison Travis stated, “My office will continue to work tirelessly with our outstanding federal, state and local partners to identify and bring justice to those who commit healthcare related crimes. This takedown was a team effort, and I commend the excellent work performed by our prosecutors and the men and women of the agencies involved.”

“Today's indictment sends a clear message to individuals like Terry Wilks and Leslie McHugh who engage in kickback schemes which defraud health care programs that they will be held accountable. Mr. Wilks and Ms. McHugh took advantage of a system set up to help patients get much-needed government assistance and instead benefitted themselves," said FBI New Orleans Special Agent in Charge Douglas A. Williams, Jr. "We would like to thank our state and federal partners with the Medicare Fraud Strike Force for their strong partnership and unrelenting pursuit of justice."

Miranda L. Bennett, Special Agent in Charge of the Department of Health and Human Services, Office of Inspector General, Dallas Region, stated: “Today’s indictment is yet another example of our commitment to vigorously defend the Medicare Trust Fund. Paying and receiving kickbacks for referrals undermines federal health care programs. We will continue to pursue those who conduct fraudulent kickback schemes to safeguard the beneficiaries of these programs.”

“I applaud my Medicaid Fraud Control Unit and our partners at the U.S. Attorney’s Office for their efforts to end criminal activity, especially when it is being perpetuated by people who are supposed to be taking care of our State’s vulnerable,” said Attorney General Jeff Landry.

This matter is being investigated by HHS-OIG, the FBI, and the Defense Criminal Investigative Service and was brought as part of the MFSF, supervised by the Criminal Division’s Fraud Section and the U.S. Attorney’s Office for the Middle District of Louisiana. The case is being prosecuted by Assistant United States Attorney Kristen L. Craig and Department of Justice Trial Attorney Justin M. Woodard.

NOTE: An indictment is an accusation by a grand jury. The defendant is presumed innocent until and unless adjudicated guilty at trial or through a guilty plea.

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President Joe Biden signed bipartisan legislation Sen. Maggie Hassan, D-N.H., authored to recruit medically-trained Veterans to pursue careers in the Department of Veterans Affairs and similar agencies upon their retirement.

The Hire Veterans Health Heroes Act of 2021 requires the VA to set up a program to reach out to all military-trained Veterans within a year of retirement about a health care occupational career in the federal government. Sen. Mike Braun, R-Ind., co-sponsored the bill with Hassan.

“We promise our Veterans that we will be there for them, and today, here at the White House, we took a small step forward in helping keep that promise,” Hassan said in a statement.

“I was proud to work with Sen. Braun on this important legislation because we must always ensure that Veterans have the support and resources that they need to succeed, and a critical way to do that is by expanding employment opportunities for our nation’s heroes and strengthening their health care.”

Biden signed Tuesday another bill Hassan had co-sponsored to expand in-state tuition eligibility for the families of Veterans who die from service-connected disabilities.

Under the new law, survivors may also qualify for the tuition benefit if a Veteran is permanently and totally disabled due to a service-connected disability.

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The bills will reform the military's use of burn pits and expand a registry of service members exposed to them

President Biden signed two bills into law Monday that could help tens of thousands of Veterans who claim they became ill from exposure to burn pits.

The pair of bills, included in the $768 billion National Defense Authorization Act (NDAA) for 2022, will bring sweeping reform to the military’s use of burn pits, expand a registry of service members exposed to the crude trash incineration method while serving overseas and enhance medical training for health care providers.

"My bills, the DOD Burn Pits Health Provider Training Act and the Burn Pit Registry Expansion Act, becoming law is a great step forward in our fight to get our Veterans affected by toxic burn pit exposure the care they deserve," Rep. Raul Ruiz, D-Calif., a doctor who authored the two bills, told Fox News.

"These much-needed bills will help address the urgent public health crisis facing our Veterans by expanding the Burn Pit Registry to a whole new group of Veterans and helping physicians quickly identify at-risk service members.

"As these new laws take effect, I will continue fighting for our nation's burn pit-exposed Veterans and service members to get them the timely care they need and end the use of burn pits once and for all."

The two bills signed into law include the Department of Defense (DoD) Burn Pits Health Provider Training Act (H.R. 4397), which will require the DoD to implement mandatory training for all medical providers working for the department on the potential health effects of burn pits. The Burn Pit Registry Expansion Act (H. R. 4400) will require the DoD and the Veterans Administration to expand their registry to include military members who were stationed in Egypt and Syria.

Both bills are expected to take effect immediately with the provider training act helping to train doctors to catch early signs of toxic exposure in an effort to provide more timely care. Many Veterans who were exposed to burn pits say that their doctors often struggled to pinpoint how young, otherwise healthy, service members with no family history of cancer were becoming ill.

"A decade ago, we went to VA health care facilities, and they just kind of shrugged their shoulders," Rosie López-Torres, founder of advocacy group Burn Pits 360, told Fox News. The two bills resulted in part from her organization's lobbying efforts on Capitol Hill the last decade.

López-Torres adds that more needs to be done to ensure that all service members are receiving the help they need.

"We are proud to see these bills become laws," she said, "But they need to expand the list of locations. We have a lot of service members saying that they are still working near active burn pits and questioning why they can’t be on the registry."

Biden has said publicly that he believes his son Beau’s terminal cancer resulted from exposure to burn pits while serving with the U.S. Army in Iraq. This past Veterans Day, the Biden administration released a statement announcing actions to develop and test a model for establishing a connection to illnesses developed after exposure to toxins released into the air as plumes of smoke rose from the burn pits. The initiative aims to provide Veterans who were exposed to burn pits with long-denied benefits.

"We’re going to work with Congress — Republicans and Democrats together — to make sure our Veterans receive the world-class benefits that they’ve earned, and meet the sacred — the specific care — specific needs that they each individually need," President Biden said during public remarks at Arlington Cemetery on Veterans Day. "That means expanding presumptive conditions for toxic exposure and particulate matter, including Agent Orange and burn pits.

"We’re going to keep pushing on this front to be more nimble and responsive," he added. "We’re reviewing all the data and evidence to determine additional presumptive conditions that make sure our Veterans don’t have to wait to get the care they need."

López-Torres says she would like to see Biden do more to include the full 23 presumptive conditions associated with burn pit exposure.

"They are spoon-feeding us a little at a time, and that’s not OK," she said. "We don’t have time to wait. People are dying."

The Investigative Unit at Fox News has reported extensively on the fears that Veterans have become sick from exposure to fumes from burn pits. Many soldiers said the pits were a crude method of incineration in which every piece of waste was burned, including plastics, batteries, appliances, medicine, dead animals and even human waste.

The items were often set ablaze with jet fuel as the accelerant. The pits burned more than 1,000 different chemical compounds day and night. Most service members breathed in toxic fumes with no protection. According to a registry created by the VA, over 200,000 Vets said the exposure made them ill, but the department denied assistance to many of them.

Many Veterans and their families have said that their experience trying get help with health care coverage left them feeling that the federal government viewed them with doubt and suspicion.

The new laws are the latest advances in a push for burn pit exposure to become a presumptive condition by the VA when addressing disabilities.

The Presumptive Benefits bill was originally introduced in September of last year but was reintroduced in March with updated criteria for presumptive care.

To simplify eligibility, the bill favors Veterans having relevant service medals received after their tour of duty instead of documentation that they served a minimum number of days, a crucial step, proponents of the bill say. Listing their service as a presumptive condition will help to provide needed care to millions of Veterans.

"These are men and women who have sacrificed everything for our country, and now they're sacrificing their lives because of diseases that are caused by their exposure that they had no say about being stationed next to a burn pit," Senator Kirsten Gillibrand, D-N.Y., a co-sponsor of the bill, told Fox News in April. "We know burn pits are deadly. That's why they're banned in the United States."

"The epidemiology already exists for most of these diseases because we know the nature of what's burned in the burn pit is identical to the stuff that was burned on 9/11 and the weeks and months on the pile thereafter. And there's a ton of work done to show causation with all the research done over the last 15 years."

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ABINGDON, Va. – A Bristol, Tennessee man was sentenced today to three months of home confinement for conspiring with another man to pay and receive kickbacks. In addition to home confinement, he will pay $56,000 in monetary penalties and will be permanently excluded from participating in federal healthcare programs.

According to court documents, John Paul Linke, 58, conspired to receive and pay kickbacks to encourage urine drug screen testing performed by a lab in Florida. Some of the testing referred to the lab was paid for by Medicare, Virginia Medicaid, and TennCare. Co-conspirator Michael Olshavasky, of Miami, Florida, will be sentenced on September 22, 2021.

“The defendant’s diversion of critical federal and state funds that were needed to target the opioid crisis for his own greed is unconscionable,” Acting U.S. Attorney Bubar stated today. “We will continue to prioritize prosecuting health care fraud cases, and that we will continue to work closely with the Virginia Attorney General’s Office, and our other critical federal and state partners, to bring such providers to justice.”

“Healthcare providers who use kickback schemes like this one are not only defrauding our healthcare system, but they’re also stealing from Virginia taxpayers just to line their own pockets,” said Attorney General Herring. “Virginians trust their healthcare providers to make the best decisions for their patients without monetary gain or outside influence. I want to thank my Medicaid Fraud Control Unit for their work on this case as well as our local, state, and federal partners for their ongoing collaboration on cases where individuals try and defraud our Medicaid and Medicare systems.”

“Those who seek to profit off the opioid crisis through illegal schemes make the problem worse,” said Special Agent in Charge Mark S. McCormack, FDA Office of Criminal Investigations Metro Washington Field Office. “We will continue to investigate and bring to justice those who, through their dishonesty, jeopardize the public health.”

Between November 30, 2015, and May 30, 2016, Linke was employed at an office-based opioid treatment program that used medication-assisted treatment for patients suffering from substance use disorder. In exchange for being paid $5,000 per month, Linke arranged for the clinic to send urine drug screen samples to the laboratory in Florida where Olshavasky worked. These payments were disguised as commissions paid to Linke as an “independent sales representative” for Olshavsky’s company, Encore Holdings LLC. Olshavasky paid Linke at least $16,000 through Encore Holdings to direct WRC’s drug screening business to the Florida lab, although Linke was not actually an independent sales representative for Encore, and he did not act as such.

The Virginia Medicaid Fraud Control Unit, the Drug Enforcement Administration, the Food and Drug Administration Office of Criminal Investigations, the Department of Health and Human Services—Office of Inspector General, the Tennessee Bureau of Investigation, and the Virginia State Police investigated the case.

Special Assistant United States Attorney Janine M. Myatt and Assistant United States Attorneys Randy Ramseyer and Whit Pierce prosecuted the case for the United States.

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TEXARKANA, Texas – A Coronado, California, man has been found guilty of federal violations related to a health care kickback scheme in the Eastern District of Texas, announced U.S. attorney Brit Featherston today.

Vincent Marchetti, Jr., 57, was found guilty by a jury following a month-long trial before U.S. District Judge Robert W. Schroeder, III.

“Fraud on our health care system cost taxpayers millions of dollars,” said U.S. Attorney Brit Featherston. “The defendant convicted today, and the others prosecuted in this large conspiracy, will suffer their fate at the hands of our excellent justice system. All should know that an investigation and prosecution such as this takes thousands of hours of work by law enforcement and prosecutors. My hat goes off to them for their excellent work to protect the citizens of our communities.”

“Kickback schemes victimize patients seeking legitimate care and line the pockets of criminals who pay or receive them,” said Miranda L. Bennett, Special Agent in Charge of the U.S. Department of Health and Human Services, Office of Inspector General, Dallas Region. “We will continue working with our law enforcement partners to protect the integrity of federal health care programs by exposing these harmful schemes and holding fraudsters accountable.”

“The defendant intentionally deceived the health care system to receive unlawful benefits and payments. Health care fraud causes billions of dollars in damages a year and affects patients by raising their premiums and taxes,” said FBI Dallas Special Agent in Charge Matthew DeSarno. “The FBI will continue working alongside our public and private sector partners to pursue individuals who attempt to profit off of patients and insurance holders.”

“Those involved in kickback schemes and fraudulent business enterprises will eventually face justice no matter where they operate,” said Christopher Miller, acting Special Agent in Charge, HSI Dallas. “We remain relentless in our pursuit of those who violate the law through fraudulent practices for personal gain.”

According to information presented in court, Marchetti conspired with others to pay and receive kickbacks in exchange for the referral of, and arranging for, health care business, specifically pharmacogenetic (PGx) tests. Pharmacogenetic testing, also known as pharmacogenomic testing, is a type of genetic testing that identifies genetic variations that affect how an individual patient metabolizes certain drugs. The illegal arrangement concerned the referral of PGx tests to clinical laboratories in Fountain Valley, California; Irvine, California; and San Diego, California. More than $28 million in illegal kickback payments were exchanged by those involved in the conspiracy.

In December 2019, twelve individuals from three states were charged for their roles in the kickback conspiracy. A federal grand jury in the Eastern District of Texas returned an indictment against Philip Lamb, 46, of Scottsdale, Arizona; Nicolas Arroyo, 40, of Tempe, Arizona; Vincent Marchetti, Jr.; William Flowers, 56, of Houston; Steven Donofrio; James J. Walker, Jr. a/k/a Jimmy Walker, 47, of Frisco; Timothy Armstrong, 64, of Frisco; Virginia Blake Herrin, 56, of Frisco; Patrick Ridgeway, 52, of Jackson, Mississippi; Chismere Mallard, 41, of McAllen; Dr. Ray W. Ng; and Ashley Kretzschmar, 36, of Aledo; for conspiring to commit illegal remunerations in violation of the Anti-Kickback Statute.

Philip Lamb, Nicolas Arroyo, Jimmy Walker, Virginia Blake Herrin, Patrick Ridgeway, Chismere Mallard, and Ashley Kretzschmar pleaded guilty prior to trial.

Kimberly Willette, 59, of Friendswood, and Edwin Chad Isbell, 48, of McKinney, also pleaded guilty to related charges.

The Anti-Kickback Statute prohibits offering, paying, soliciting, or receiving remunerations in exchange for the referral of or arranging for or recommending the ordering of items or services payable under federal health care programs. Under federal statutes, violations of the Anti-Kickback statute are punishable by up to five years in federal prison.

This case was investigated by the U.S. Department of Health and Human Services, Office of Inspector General, the FBI Dallas – Frisco Resident Agency, and the U.S. Department of Homeland Security, Homeland Security Investigations. It was prosecuted by Assistant U.S. Attorneys Nathaniel C. Kummerfeld, Lucas Machicek, Adrian Garcia, Brent Andrus, and L. Frank Coan, Jr., with assistance from Assistant U.S. Attorney Stephan E. Oestreicher, Jr., and Special Assistant U.S. Attorney Laurel E.P. Simmons.

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BENTON, Ill. – A Carterville man was sentenced on Thursday, September 16 to four years of probation for drug diversion and health care fraud charges. Joseph M. Mattingly, 42, was also ordered to pay a $500 fine along with a $200 special assessment.

According to court documents, Mattingly diverted Schedule II controlled substance (Hydrocodone) pills from a patient and defrauded the Medicare program of the cost of the pills.

In 2018, Mattingly was employed as a nurse with Progress Port, a center for adults with intellectual disabilities in Williamson County. Between August 20, 2018 and October 30, 2018, Mattingly obtained possession of 25 Hydrocodone pills he falsely claimed he dispended to a Progress Port resident, which he diverted for his own personal use.

Mattingly took three Hydrocodone pills intended for the same Progress Port resident and replaced those pills with Tylenol, an over-the-counter medication at three separate locations.

The investigation was conducted by the United States Department of Health and Human Services, Office of Inspector General - Office of Investigations and the Illinois State Police Medicaid Fraud Control Bureau.

If you suspect or know of an individual or company that is not complying with healthcare laws or public aid programs, you may report this activity to the local office of the U.S. Department of Health and Human Services, Office of Inspector General, or you may call 1.800.447.8477.

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Veterans Affairs leaders are phasing out the department’s office in charge of community care programs, a move that some advocates are decrying as unfairly limiting Veterans’ medical options but officials insist is only about efficiency and not sweeping policy changes.

Last week, VA officials said they would begin a multi-month process of “designing a new integrated access and care coordination model to better deliver seamless care.”

Connected to that, lawmakers on Capitol Hill received letters from VA Secretary Denis McDonough announcing that the Office of Community Care would be decommissioned in coming months, with its responsibilities shifted to a yet-to-be-established Office for Integrated Veterans Care.

“Implementation of these changes allows the Veterans Health Administration to continue its modernization journey and transformation to operate as a high reliability, Veteran-centric organization,” the letter stated.

The issue of community care — where Veterans can see private-sector doctors paid for by department funds — has been a contentious one within VA for years.

Former President Donald Trump made expanding outside medical access a key point of his 2016 campaign and presidency, pushing for more “choice” for Veterans in where they received their health care.

But Democratic lawmakers — including President Joe Biden — have cautioned that too much use of private-sector doctors for core VA medical responsibilities could drain finances from the VA health care system and lead to “privatization” of the department.

In a statement to Military Times, Donald Koenig, special advisor to VA’s acting Under Secretary for Health for Integrated Veteran Care, said the goal of the new changes is not to hamper or dismantle the community care program.

“Nothing we are doing will change any appointments scheduled now or in the future,” he said. “We’re working to simplify, coordinate better, and make scheduling faster for Veterans, whether for a VA provider or a community care provider. Our goal is to deliver the right care at the right time, that best meets our Veteran’s health needs.”

Officials at Concerned Veterans of America — longtime advocates of increased community care programs and critics of the VA health care system — see it differently.

They noted that VA also recently took down a web page devoted to explaining Veterans’ options under the community care program, effectively limiting public information about how to enroll or schedule outside appointments.

“The administration does not like community care,” said Darin Selnick, senior advisor to the group and former Veterans Affairs advisor for the Trump White House. “If they are renaming and neutering offices and moving around access to the revenue, it feels like it is part of a campaign to get rid of it completely.”

Koenig said the Office of Community Care won’t be fully shut down until next spring, with a target now of March 2022.

About 3,600 employees will be transferred to the new integrated care office, while another 4,300 will be reassigned to the Veterans Health Administration’s finance office. No jobs will be terminated or physically relocated.

But Selnick said CVA has heard from numerous Veterans and congressional offices about increased problems accessing the program and getting outside medical appointments. He said the decision to separate the financial and operational functions of the program could cause even more delays and confusion.

VA officials say that’s not true, noting that community care referrals were up about 12 percent last month compared to 2019 levels (September 2020 levels were down about 6 percent, but VA leaders say that’s because of reduced demand related to the coronavirus pandemic.)

Lawmakers received a briefing on the looming changes this week. House Veterans’ Affairs Committee ranking member Mike Bost, R-Ill., said he supports efforts to improve the community care program, but said he is leery of the moves so far.

“I am hearing more and more often from Veterans who are not being given the choices they are entitled to under the law,” he told Military Times. “I am very concerned that this will divert much-needed focus from community care and make it that much easier for wait times to creep back up and Veterans to suffer for it, just like they did in 2014.

“It’s on Secretary McDonough to make sure that doesn’t happen, and I will be keeping very close watch.”

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Last of Four Individuals Sentenced in this Conspiracy

An Illinois woman was sentenced yesterday in the Northern District of Illinois to 56 months in prison and ordered to pay $6.3 million in restitution for her participation in a conspiracy to commit health care and wire fraud.

According to court documents, and the evidence presented at trial, Angelita Newton, 43, of Chicago, worked at Care Specialists, a home health care company owned by Ferdinand Echavia and later his wife, Ma Luisa Echavia. While operating between 2011 and 2017, Care Specialists fraudulently billed Medicare at least $6.3 million. At trial, the government demonstrated that around 90% of the patients were not homebound and did not qualify for the types of care that Care Specialists billed Medicare for. Further, many patients received cash bribes to receive home health “visits,” some of which were performed in the visiting nurse’s car. Newton facilitated the conspiracy by falsifying patient visit records which were used to support claims billed to Medicare and was convicted by a federal jury on Feb. 14, 2020.

In addition to issuing Newton’s sentence today, Judge Virginia Kendall previously sentenced three others involved in the conspiracy. On Oct. 21, 2021, Ferdinand Echavia was sentenced to 84 months’ confinement and three years’ supervised release. On Nov. 5, 2021, Ma Luisa Echavia was sentenced to 60 months’ confinement and three years’ supervised release. Another participant in the conspiracy, Reginald Onate, who pleaded guilty and cooperated with the government throughout the investigation, was sentenced to a term of three years’ probation.

Assistant Attorney General Kenneth A. Polite Jr. of the Justice Department’s Criminal Division, Acting Assistant Director Jay Greenberg of the FBI’s Criminal Investigative Division, and Special Agent in Charge Mario Pinto of the Department of Health and Human Services, Office of the Inspector General (HHS-OIG) made the announcement.

The FBI Chicago Field Office and HHS-OIG investigated the case.

Trial Attorney Leslie S. Garthwaite of the Criminal Division’s Fraud Section and Assistant U.S. Attorney Patrick Mott (formerly of the Fraud Section) prosecuted the case.

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Hattiesburg, Miss. – A Columbia, Mississippi woman pled guilty in U.S. District Court to one count of health care fraud.

According to court documents, beginning in 2016 and continuing for well over two years, Joy Beth Harden, 51, executed a scheme to defraud Medicare and other health care benefit programs. Specifically, Harden submitted fraudulent bills for durable medical equipment on behalf of her business, BZB LLC doing business as Duracare Home Medical Equipment in the Hattiesburg area. As a result, Medicare and other benefits programs paid Harden for durable medical equipment that was never prescribed for patients and for medical equipment that was never delivered to the patients.

Harden pled guilty on Tuesday, August 10, 2021. She will be sentenced on November 23, 2021, and faces a maximum penalty of 10 years in federal prison and a $250,000 fine. A federal district judge will determine any sentence after considering the U.S. Sentencing Guidelines and other statutory factors. Harden remains in federal custody awaiting sentencing.

The announcement was made by Acting U.S. Attorney Darren J. LaMarca, Acting Special Agent in Charge Paul W. Brown of the Federal Bureau of Investigation in Mississippi, Special Agent in Charge Derrick L. Jackson of U.S. Department of Health & Human Services, Office of Inspector General (HHS OIG) Atlanta Regional Office, Special Agent in Charge Cynthia A. Bruce of the DoD OIG, Defense Criminal Investigative Service (DCIS) Southeast Field Office, and Inspector General Martin J. Dickman of U.S. Railroad Retirement Board, Office of Inspector General (RRB OIG).

The case was prosecuted by Deputy Criminal Chief Dave Fulcher.

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Hattiesburg, Miss. – A Columbia, Mississippi woman was sentenced to 57 months in prison for defrauding health care insurance providers.

Joy Beth Harden, 51, pled guilty on August 10, 2021, to executing a scheme to defraud Medicare and other health care benefit programs. Specifically, Harden submitted fraudulent bills for durable medical equipment on behalf of her business, BZB LLC doing business as Duracare Home Medical Equipment in the Hattiesburg area. As a result, Medicare and other benefits programs paid Harden for durable medical equipment that was never prescribed for patients and for medical equipment that was never delivered to the patients.

United States District Judge Taylor B. McNeel sentenced Harden on April 15, 2022, to serve a term of 57 months in federal prison, followed by a term of 3 years of supervised release. Harden was also ordered to pay full restitution to all of the health care insurers she defrauded.

The announcement was made by United States Attorney Darren J. LaMarca, Special Agent in Charge Jermicha Fomby of the Federal Bureau of Investigation in Mississippi, Special Agent in Charge Tamala Miles of the U.S. Department of Health & Human Services, Office of Inspector General (HHS OIG) Atlanta Regional Office, Special Agent in Charge Cynthia A. Bruce of the DoD OIG, Defense Criminal Investigative Service (DCIS) Southeast Field Office, and Inspector General Martin J. Dickman of the U.S. Railroad Retirement Board, Office of Inspector General (RRB OIG).

“Submitting claims for unsubstantiated services threaten the integrity of the Medicare program and increases the financial burden on taxpayers,” stated Tamala Miles, Special Agent in Charge with the Department of Health and Human Services Office of Inspector General (HHS-OIG). “Working closely with our partners, HHS-OIG will continue to safeguard the integrity of federal health care programs by investigating individuals who seek to exploit them.”

“Health care fraud threatens the most vulnerable of our citizens by endangering the programs which provide care for them," stated Jermicha Fomby, Special Agent in Charge of the FBI in Mississippi. “It is imperative we proactively root out such acts as this fraud which erode the fabric of our healthcare system upon which our citizens depend. I want to commend the investigators and prosecutors who worked together on this case. We look forward to continued partnerships such as this among the law enforcement community in Mississippi.”

“There are no victimless crimes. Stealing money from the Defense Health Agency (DHA) and Medicare is stealing money from all taxpayers,” stated Special Agent in Charge Cyndy Bruce, Office of the Inspector General (DoD-OIG), Defense Criminal Investigative Service (DCIS), Southeast Field Office. “DCIS and our investigative partners will continue to come after those who seek to illegally enrich themselves and hold them accountable for their actions.”

“The U.S. Railroad Retirement Board, Office of Inspector General (RRB-OIG) is committed to fighting Medicare fraud, waste, and abuse and is proud to be part of this collaborative effort with the FBI, HHS-OIG, and DoD-OIG,” said Inspector General Martin J. Dickman. “The sentencing of Joy Beth Harden sends a loud and clear message that combating Medicare fraud is a top federal law enforcement priority and unscrupulous Medicare providers will not be tolerated.”

This case was investigated by the HHS-OIG, FBI, DCIS, and RRB-OIG. The case was prosecuted by Deputy Criminal Chief Dave Fulcher.

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Veterans Affairs officials want to drop copay expenses for Veterans facing mental health challenges as a way to encourage more individuals to seek help when facing suicidal thoughts.

Department leaders on Wednesday published plans in the Federal Register to modify VA’s copayment rules, with the goal of reforming the policy in coming months.

In a statement, VA Secretary Denis McDonough said the move is part of broader suicide prevention and health care outreach efforts by the department.

“Research shows increased frequency of outpatient mental health encounters for high-risk Veterans reduces their risk of suicide,” he said. “Through these efforts, VA will continue to address this national public health crisis by further eliminating financial burdens on Veterans which may negatively influence their engagement in mental health treatment and their critical medication availability.”

Veterans who use VA as their primary health care provider do not have to pay any extra fees when receiving care at a department hospital. But Veterans seeking mental care at outpatient clinics can face copayments for appointments, typically ranging from $15 to $50.

Advocates say even those small amounts can present a potential barrier to a Veteran in distress who needs immediate assistance. And the costs can compound quickly in cases where Veterans need multiple visits in a month, often to refill medications.

Officials said the new move “would reduce the financial burden of multiple co-payments associated with both increased outpatient visits as well as more frequent, but limited supply of prescribed medications.”

Last fall, VA officials announced that Veterans suicides across America in 2019 fell to about 17 per day, their lowest level in 12 years.

The latest data available does not take into account the ongoing coronavirus pandemic, which began in March 2020, but VA officials preliminary research has not shown a significant increase in those numbers over the last two years.

Still, suicide prevention remains a key focus of VA leadership and the White House, as it has been for the last three presidential administrations. Even with the decrease, the rate of suicide among Veterans remains almost double the rest of the American public.

Members of the public can comment on the planned copayment rule through the Federal Register until March 7.

Veterans experiencing a mental health emergency can contact the Veteran Crisis Line at 1-800-273-8255 and select option 1 for a VA staffer. Veterans, troops or their family members can also text 838255 or visit VeteransCrisisLine.net for assistance.

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HARRISBURG - The United States Attorney’s Office for the Middle District of Pennsylvania announced that Rodney L. Yentzer, age 52, of Cumberland County, Pennsylvania was charged in a criminal information with one count of conspiracy to commit health care fraud, one count of conspiracy to commit money laundering, and one count of theft of public money for defrauding Medicare and the U.S. Department of Health and Human Services between 2016 and 2020.

According to United States Attorney John C. Gurganus, the information alleges that Yentzer agreed with others to defraud Medicare by submitting bill for medically unnecessary urine drug tests for chronic opioid patients at medical clinics he controlled, including a group of clinics known as Pain Medicine of York or “PMY” (also known as All Better Wellness).

It is alleged that PMY billed Medicare for more than $10 million in urine drug tests from mid-2017 through the end of 2019. As a result, Medicare paid out over $4 million for these urine drug tests. Pennsylvania’s Medicaid program was also billed for urine drug tests during this same time period. The urine drug tests ordered by PMY were sent to an in-house laboratory at PMY whenever possible. As a result, when medically unnecessary tests were billed to Medicare, the proceeds from them went to PMY itself.

The information also alleges that Yentzer received over $191,000 in U.S. Department of Health and Human Services stimulus money that was intended for health care providers who had health care related expenses and lost revenues attributable to COVID-19. Yentzer obtained these funds in April 2020, even though he had resigned from PMY the prior month and PMY had been closed since late 2019.   Yentzer allegedly used these funds on various things unrelated to COVID-19 relief, including personal expenses.

Search warrants were executed at PMY’s various locations in November 2019, and PMY ceased operations soon thereafter.

The case was investigated by the U.S. Department of Health and Human Services Office of Inspector General, Federal Bureau of Investigation, Drug Enforcement Administration, and the Pennsylvania Office of Attorney General. Assistant U.S. Attorney Ravi Romel Sharma and Special Assistant U.S. Attorney Robert Smultkis are prosecuting the case.

The maximum penalty under federal law for conspiracy to commit health care fraud is 10 years’ imprisonment. The maximum penalty law for conspiracy to commit money laundering is 20 years’ imprisonment. The maximum penalty law for theft of public money is 10 years’ imprisonment. These charges may also carry a fine and a term of supervised release following imprisonment. A sentence following a finding of guilt is imposed by the Judge after consideration of the applicable federal sentencing statutes and the Federal Sentencing Guidelines.

Informations are only allegations. All persons charged are presumed to be innocent unless and until found guilty in court.

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Veterans Affairs officials would set up 31 major medical clinics across America and hire thousands more claims processors and health care staff under compromise toxic exposure legislation unveiled in the Senate Tuesday.

The provisions would be attached to the already massive Promise to Address Comprehensive Toxics Act (or PACT Act) which passed out of the House in March. That measure carried a price tag of more than $200 billion over the next decade and would potentially affect as many as one in five Veterans living in America today.

Concerns about the scope of the bill and the potential of the new Veterans benefits to overwhelm existing VA systems led to resistance from Republican lawmakers.

But last week, the Democratic and Republican leaders of the Senate Veterans’ Affairs Committee announced a breakthrough to advance the legislation, somewhat surprisingly by broadening the bill’s scope even further.

In a statement released Tuesday afternoon, committee Chairman Jon Tester, D-Mont., and Jerry Moran, R-Kansas, said they believe the new plan can pass through Congress and provide Veterans suffering from toxic exposure injuries with the services they deserve.

“This legislation expands VA health care eligibility for post-9/11 combat Veterans, improves VA’s claims processing, and delivers VA the necessary resources to take care of our Veterans from every generation,” they said.

“While our work is far from over, together we’re committed to keeping up our end of the bargain to those who sacrificed on behalf of our freedoms by getting this bill across the finish line as soon as possible.”

In a separate statement, House Veterans Affairs Committee Chairman Mark Takano, D-Calif., offered support for the compromise bill, which will have to be again approved by his chamber before becoming law.

“I have long said that we cannot let cost or implementation hurdles get in the way of making good on our promise,” he said. “Toxic-exposed Veterans do not have time to wait.”

Senate officials did not release any estimates for what the revised PACT Act may cost.

Benefits for burn pit victims and more

As in the House plan, the Senate compromise would establish a presumption of service connection for 23 respiratory illnesses and cancers related to the smoke from burn pits, used extensively in those war zones to dispose of various types of waste, many of them toxic.

The bill also provides for new benefits for Veterans who faced radiation exposure during deployments throughout the Cold War, adds hypertension and monoclonal gammopathy to the list of illnesses linked to Agent Orange exposure in the Vietnam War, expands the timeline for Gulf War medical claims and requires new medical exams for all Veterans with toxic exposure claims.

Veterans who served in Thailand, Laos, Cambodia and Guam during the Vietnam War era would be covered for the first time under the same Agent Orange presumptive policies as those who served in Vietnam itself.

The bill would also require a significant reconsideration of how VA handles toxic exposure claims, with a formal working group on toxic exposure injuries and research advising top officials on future improvements.

VA officials would be granted “the authority to determine that a Veteran participated in a toxic exposure risk activity when an exposure tracking record system does not contain the appropriate data,” a sharp contrast from the science-only system in use at VA today.

Advocates have lamented that in many cases, Veterans with serious illnesses obviously connected to their service have been turned away by the department because ironclad data showing chemical exposure during their service does not exist.

Phasing each of those provisions into law won’t happen immediately, however.

For example, hypertension will be added to the list of presumptive conditions caused by Agent Orange exposure during the Vietnam War right away for individuals “who are terminally ill, homeless, under extreme financial hardship, or are over 85 years old.”

For other Vietnam War Veterans, that won’t go into effect until October 2026.

Chronic bronchitis would be added to the list of presumptive illnesses caused by burn pits in October 2023. Kidney cancer would not be included in the same category until two years later.

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Fox Chase-area Pharmacy was the Top Retail Purchaser of Oxycodone in Pennsylvania

PHILADELPHIA – United States Attorney Jennifer Arbittier Williams announced that the United States filed an amended civil complaint against pharmacist Todd Goodman and pharmacy employees Eric Pestrack and Lee Kamp for their alleged involvement in years-long practices of illegally dispensing opioids and other controlled substances, and systematic health care fraud, at Philadelphia-based pharmacy Spivack, Inc., which previously operated under the name Verree Pharmacy. These individuals were added as defendants in the previously filed lawsuit against Verree and its former owner, pharmacist Mitchell Spivack, for the same alleged schemes. The amended complaint continues to seek civil penalties and civil damages, which could total in the millions of dollars, as well as injunctive relief.

The lawsuit, in which Goodman, Pestrack, and Kamp were added, was the culmination of a multi-year federal-state investigation. The amended complaint alleges that Verree Pharmacy, Spivack, Goodman, Pestrack, and Kamp had a responsibility to dispense opioids and other controlled substances only when appropriate. Instead, the United States alleges that Verree and these individuals dispensed the drugs, even when faced with numerous red flags suggestive of diversion—such as opioids in extreme doses, dangerous combinations of opioids and other “cocktail” drugs preferred by those struggling with addiction, excessive cash payments for the drugs, blatantly forged prescriptions, and other signs that the pills were being diverted for illegal purposes.

The amended complaint alleges that Verree—which was the top retail pharmacy purchasing oxycodone in Pennsylvania—has been a nationwide and regional outlier in its deviant purchasing, dispensing, and billing of controlled substances. To avoid scrutiny from the drug distributors that sold them the pills, Verree through Spivack allegedly made false statements to maintain the façade of legitimacy and keep the pharmacy stocked with pills critical to its profits. Behind that façade, the amended complaint alleges that Spivack drew millions of dollars from the pharmacy while the public suffered the consequences, including one patient who overdosed and died next to Verree Pharmacy bottles dispensed by Spivack.

The United States’ amended complaint also alleges that Verree, Spivack, Goodman, Pestrack, and Kamp were engaging in an expansive health care fraud scheme involving fraudulent billings for drugs not actually dispensed. The alleged cornerstone of the scheme was a code used by the pharmacy employees in their internal computer system: “BBDF” or “Bill But Don’t Fill.” Verree, Spivack, Goodman, Pestrack, and Kamp allegedly used BBDF as a means to cover their losses on other drugs and further the pharmacy’s illicit profits by falsely claiming to insurers, including Medicare, that they had dispensed a drug to a patient, when in fact they had not. According to the amended complaint, this sophisticated fraud—which one of the employees admitted to investigators—resulted in significant losses to Medicare and other federal programs.

The lawsuit seeks to impose civil penalties and damages on Verree, Spivack, Goodman, Pestrack, and Kamp under the Controlled Substances and False Claims Acts. If Verree, Spivack, Goodman, Pestrack, and Kamp are found liable, they could face civil penalties up to $68,426 for each unlawful prescription dispensed, civil penalties up to $23,607 for each false claim they submitted to federal health care programs, and treble damages for the alleged health care fraud against federal programs. The court may also award injunctive relief to prevent the defendants from committing additional controlled substance violations.

If the public has any information regarding Verree Pharmacy or any other health care fraud allegation, individuals should contact the HHS-OIG hotline at 800-HHS-TIPS.

The case is being investigated by the Philadelphia Field Division of the Drug Enforcement Administration, the Pennsylvania Department of State’s Bureau of Enforcement and Investigation, HHS-OIG, and the Pennsylvania Office of the Attorney General, with additional assistance from the Office of Personnel Management Office of Inspector General, the Defense Health Agency, and the Defense Criminal Investigative Service. The civil investigation and litigation are being handled by Assistant United States Attorney Anthony D. Scicchitano and auditors Dawn Wiggins and George Niedzwicki.

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EL PASO – An El Paso businesswoman and her nephew were arrested today on criminal charges for their alleged roles in committing health care fraud.

According to court documents, Zenia Chavez, 45, and Raul Alejandro Fuentes, 23, of El Paso, conspired together to commit health care fraud. Chavez is the owner and Fuentes is an employee of Nursemind Home Health, Inc. (Nursemind), which provides hospice care services. The defendants sought out people in boarding homes and senior living facilities for enrollment in a Nursemind hospice program although they did not need hospice care or have a terminal illness. The defendants then created false and fraudulent medical records for the individuals, forged health personnel signatures, and submitted fraudulent claims to Medicare. In addition, Chavez is also charged with offering kickbacks for client referrals to Nursemind.

Chavez and Fuentes are charged with one count of conspiracy to commit health care fraud, and 14 counts of health care fraud. Chavez is also charged with one count of conspiracy for illegal remunerations regarding a federal health care program and 11 counts of illegal remunerations regarding a federal health care program. If convicted, Chavez and Fuentes face a maximum penalty on each of the health care fraud counts of 10 years in prison. Chavez faces an additional five years in prison on the conspiracy for illegal remunerations charge and 10 years in prison on each of the illegal remuneration counts. A federal district judge will determine any sentence after considering the U.S. Sentencing Guidelines and other statutory factors.

U.S. Attorney Ashley C. Hoff of the Western District of Texas; FBI Special Agent in Charge Jeffrey Downey, El Paso Division; and U.S. Department of Health and Human Services Office of Inspector General (HHS OIG) Special Agent in Charge Miranda Bennett made the announcement.

The FBI and HHS OIG are investigating the case.

Assistant U.S. Attorneys Chris Skillern and Debra Kanof are prosecuting the case.

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Flu and COVID-19 can both lead to serious illness

Getting a flu vaccine this fall is more important than ever to protect yourself, your family, friends, and coworkers. We are facing a tough 2020 flu season as we prepare to battle the coronavirus at the same time.

Flu shots protect you against flu. By getting a flu shot, you will be less likely to spread flu to others. By keeping you healthy, our VA facilities won’t be overwhelmed with flu patients during the pandemic.

Flu and COVID-19

Flu and COVID-19 can lead to serious health complications resulting in hospitalization or death. The good news is both may be prevented by wearing a face covering, practicing physical distancing, washing your hands frequently and coughing into your elbow.

Everyone needs a flu shot

The Centers for Disease Control and Prevention (CDC) recommends that everyone six months or older should get a yearly flu shot. Flu can be serious among young children, older adults and those with chronic health conditions, such as asthma, heart disease or diabetes.

Every year, hundreds of thousands of Americans are hospitalized with the flu.

During the 2019-2020 flu season, more than 4,600 Veterans were hospitalized at VA medical centers. More than 600 of them required intensive care stays. VA providers also saw over 27,000 Veterans for flu and spoke to more than 13,000 during phone triage calls.

Flu season is near, so talk to your health provider about where to safely get a flu shot this fall.

Shots at retail pharmacies

If you are enrolled in VA health care, you can receive the seasonal flu vaccination at more than 60,000 locations through the Community Care Network in-network retail pharmacies and urgent care partners. VA will pay for standard-dose and high-dose flu shots. Even if you haven’t had a flu shot lately, make this the year that you do!

On Sept. 1, enrolled Veterans can visit https://www.va.gov/communitycare/flushot.asp to find locations to get a no-cost flu shot.

Help us help you: we are fighting flu and COVID-19 together.

Important Resources

• Influenza
• COVID-19
• Coronavirus Frequently Asked Questions
• CDC Similarities and Differences Between Flu and COVID-19

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NCH Healthcare System (NCH), which operates two hospitals in Collier County, Florida, has agreed to pay the United States $5.5 million to resolve allegations that it made donations to local units of government to improperly fund the state’s share of Medicaid payments to NCH.

The Florida Medicaid program provides medical assistance to low-income individuals and individuals with disabilities, and is jointly funded by the federal and state governments. Under federal law, Florida’s share of Medicaid payments must consist of state or local government funds, and not “non-bona fide donations” from private health care providers, such as hospitals. A non-bona fide donation is a payment — in cash or in kind — from a private provider to a governmental entity that is then returned to the private provider as the state share of Medicaid. The private provider’s donation triggers a corresponding federal expenditure for the federal share of Medicaid, which is also paid to the private provider. This unlawful conduct causes federal expenditures to increase without any corresponding increase in state expenditures, since the state share of the Medicaid payments to the provider comes from and is returned to the provider. The prohibition of this practice ensures that states are in fact paying a share of Medicaid payments and thus have an incentive to curb Medicaid costs and prevent unnecessary services.

The United States alleged that, between October 2014 and September 2015, NCH made improper, non-bona fide donations by: (1) providing free nursing and athletic training services to the Collier County School Board; and (2) assuming and paying certain of Collier County’s financial obligations. Both types of donations were designed to increase Medicaid payments received by NCH, without any actual expenditure of state or local funds. In particular, NCH’s donations freed up funds for the county and school board to make payments to the State as the state share of Medicaid payments to NCH. This state share was “matched” by the federal government before being returned to NCH as Medicaid payments. The Medicaid payments NCH received were thus funded by the federal government and NCH’s own donations, in violation of the prohibition on non-bona fide donations.

“States and local units of government must use their own money when seeking federal Medicaid matching funds to help ensure that Medicaid payments are determined by beneficiaries’ medical needs rather than donations by hospitals or other health care providers,” said Acting Assistant Attorney General Brian M. Boynton of the Justice Department’s Civil Division. “When private parties violate the rules by making improper donations to fund the state share of Medicaid, they endanger the integrity of the Medicaid program.”

“Millions of Floridians depend on the Medicaid Program for medical care and related services,” said U.S. Attorney Roger B. Handberg for the Middle District of Florida. “This settlement underscores our commitment to protecting the integrity of the Medicaid program by ensuring that government funds are legally obtained and used for their intended purposes.”

The resolution obtained in this matter was the result of a coordinated effort between the Justice Department’s Civil Division, Commercial Litigation Branch, Fraud Section, and the U.S. Attorney’s Office for the Middle District of Florida, with assistance from the U.S. Department of Health and Human Services Office of Inspector General.

The matter was handled by Fraud Section Attorneys Alison B. Rousseau and Jonathan T. Thrope and Assistant U.S. Attorney Carolyn B. Tapie.

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PITTSBURGH, PA - A former physician who operated private family practices in Perryopolis, Pennsylvania, and Mount Pleasant, Pennsylvania, has been sentenced in federal court to 18 months’ incarceration, followed by three years supervised release, and ordered to pay a $5,000 fine on his conviction of violating federal narcotics and health care laws, United States Attorney Cindy K. Chung announced today.

United States District Judge J. Nicholas Ranjan imposed the sentence on Emilio Ramon Navarro, 60, of Coal Center, Pennsylvania.

According to the information presented to the court, Navarro, a licensed physician in the Commonwealth of Pennsylvania, operated private family practices in Mount Pleasant and Perryopolis. In 2018, Navarro issued Victim 1 nine prescriptions for a total of 300 dosage units of Oxycodone and 240 dosage units of Oxymorphone, both Schedule II controlled substances, outside the usual course of professional practice and for no legitimate medical purpose. Rather, Navarro forced Victim 1 to engage in sexual acts with him prior to issuing her these prescriptions to which he caused her to be addicted. Navarro thereby caused the submission of fraudulent claims to Medicaid for reimbursement for the unlawfully prescribed prescriptions thereby defrauding Medicaid.

Prior to imposing the sentence, Judge Ranjan stated, “There are victims involved and they have suffered lasting impacts.”

“Today’s sentence holds Dr. Navarro accountable for his illegal activities,” said U.S. Attorney Chung. “I will continue our office’s tenacious pursuit of unscrupulous doctors who exploit the addictions of patients for personal gratification and then cause our healthcare system to be defrauded.”

“Dr. Navarro had a clear disregard for medical integrity,” said FBI Pittsburgh Special Agent in Charge Mike Nordwall. “He preyed on victims struggling with addiction and traded drugs for sex. The FBI will continue to work with our partners to hold accountable those who abuse their positions of trust.”

“When Dr. Navarro prescribed opioid prescriptions in exchange for sexual favors, he abandoned his duty as a physician and recklessly discarded the health and safety of his patients,” said Special Agent in Charge Maureen R. Dixon of the U.S. Department of Health and Human Services. “Together with our law enforcement partners, our agency will continue to uproot such egregious fraud schemes that threaten public health and wastes taxpayer dollars.”

“Navarro held a position of trust in his community and his patients depended on him to provide medical care,” said AG Shapiro. “He will now face consequences for showing no regard for the health and safety of his patients, illegally prescribing drugs that have fueled the opioid crisis here in Pennsylvania, and defrauding our Commonwealth's Medicaid Program. The Office of Attorney General's arrests of prescribers who divert prescription drugs are up 135% since 2016. We will continue to work with our partners to seek out those who put lives at risk and hold them accountable.”

Assistant United States Attorneys Robert S. Cessar and Mark V. Gurzo are prosecuting this case on behalf of the government.

The investigation leading to the prosecution of Emilio Navarro was conducted by the Western Pennsylvania Opioid Fraud and Abuse Detection Unit (OFADU). The Western Pennsylvania

OFADU, led by federal prosecutors in the U.S. Attorney’s Office, combines the expertise and resources of federal and state law enforcement to address the role played by unethical medical professionals in the opioid epidemic. The agencies which comprise the Western Pennsylvania OFADU include: Federal Bureau of Investigation, U.S. Health and Human Services – Office of Inspector General, Drug Enforcement Administration, Internal Revenue Service-Criminal Investigations, Pennsylvania Office of Attorney General - Medicaid Fraud Control Unit, Pennsylvania Office of Attorney General – Bureau of Narcotic Investigations, United States Postal Inspection Service, U.S. Attorney’s Office – Criminal Division, Civil Division and Asset Forfeiture Unit, Department of Veterans Affairs-Office of Inspector General, Food and Drug Administration-Office of Criminal Investigations, U.S. Office of Personnel Management – Office of Inspector General and the Pennsylvania Bureau of Licensing.

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PITTSBURGH, PA - A former physician has been sentenced in federal court to one day of imprisonment, to be followed by three years of supervised release, including 15 months home confinement and 300 hours community service, on his conviction of drug diversion, health care fraud and money laundering, associated with his suburban Pittsburgh holistic medical practice, Acting United States Attorney Stephen R. Kaufman announced today.

Senior United States District Judge Nora Barry Fischer imposed the sentence on Andrzej Kazimierz Zielke, 66, of Allison Park, Pennsylvania 15101.

According to information presented to the court, Zielke owned and operated Medical Frontiers, LLC, a purported pain management practice, located in Gibsonia, Pennsylvania. On or about October 3, 2017, May 25, 2017, October 3, 2017, and December 17, 2014, Zielke knowingly dispensed and distributed Schedule II drugs, including Oxycodone, Methadone, Hydrocodone and Oxymorphone, to four patients outside the course of professional practice and not for a legitimate medical purpose. Zielke committed health care fraud by causing fraudulent claims to be submitted to Medicaid for payments to cover the costs of the unlawfully prescribed drugs. Finally, Zielke violated federal money laundering statutes when he caused approximately $150,000 in proceeds obtained through his illegal drug distribution to be wired from a bank account to Kitco Metals, Inc., in Canada to purchase silver and collector coins.

In addition to the criminal penalties, Zielke agreed to forfeit $75,359 in U.S. currency and an unvalued amount of gold coins and bullion.

Assistant United States Attorney Robert S. Cessar, and Special Assistant United States Attorney Summer F. Carroll prosecuted this case on behalf of the government.

The investigation leading to the filing of charges in this case was conducted by the Western Pennsylvania Opioid Fraud and Abuse Detection Unit (OFADU). The Western Pennsylvania OFADU, led by federal prosecutors in the U.S. Attorney’s Office, combines the expertise and resources of federal and state law enforcement to address the role played by unethical medical professionals in the opioid epidemic.

The agencies which comprise the Western Pennsylvania OFADU include: Federal Bureau of Investigation, U.S. Health and Human Services – Office of Inspector General, Drug Enforcement Administration, Internal Revenue Service-Criminal Investigations, Pennsylvania Office of Attorney General - Medicaid Fraud Control Unit, Pennsylvania Office of Attorney General – Bureau of Narcotic Investigations, United States Postal Inspection Service, U.S. Attorney’s Office – Criminal Division, Civil Division and Asset Forfeiture Unit, Department of Veterans Affairs-Office of Inspector General, Food and Drug Administration-Office of Criminal Investigations, U.S. Office of Personnel Management – Office of Inspector General and the Pennsylvania Bureau of Licensing.

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PITTSBURGH, PA - A former Pittsburgh-area physician pleaded guilty in federal court to violating federal narcotics and health care laws, Acting United States Attorney Stephen R. Kaufman announced today.

Emilio Ramon Navarro, 60, of Coal Center, Pennsylvania, 15423 pled guilty to one count of unlawful distribution of oxycodone and one count of health care fraud before United States District Judge J. Nicholas Ranjan. Navarro also accepted responsibility for eight additional counts of unlawful distribution of Schedule II controlled substances.

In connection with the guilty plea, the court was advised that Navarro was a licensed physician in the Commonwealth of Pennsylvania and operated private family practices in Mount Pleasant and Perryopolis, Pennsylvania. In 2018, Navarro issued Victim 1 nine prescriptions for a total of 300 dosage units of oxycodone and 240 dosage units of oxymorphone, both Schedule II controlled substances, outside the usual course of professional practice and for no legitimate medical purpose but in exchange for sexual favors. Navarro then submitted fraudulent claims to Medicaid for reimbursement for the unlawfully prescribed prescriptions thereby defrauding Medicaid.

Judge Ranjan scheduled sentencing for March 1, 2022, at 2:00 p.m. The law provides for a total sentence of not more than 20 years in prison, a fine of $1,000,000, or both, for the narcotics conviction. Navarro faces an additional maximum term of imprisonment of not more than 10 years, a fine of $250,000, or both, for the health care fraud conviction. Under the Federal Sentencing Guidelines, the actual sentence imposed is based upon the seriousness of the offenses and the prior criminal history, if any, of the defendant.

Assistant United States Attorneys Robert S. Cessar and Mark V. Gurzo are prosecuting this case on behalf of the government.

The investigation leading to the filing of charges in this case was conducted by the Western Pennsylvania Opioid Fraud and Abuse Detection Unit (OFADU). The Western Pennsylvania OFADU, led by federal prosecutors in the U.S. Attorney’s Office, combines the expertise and resources of federal and state law enforcement to address the role played by unethical medical professionals in the opioid epidemic.

The agencies which comprise the Western Pennsylvania OFADU include: Federal Bureau of Investigation, U.S. Health and Human Services – Office of Inspector General, Drug Enforcement Administration, Internal Revenue Service-Criminal Investigations, Pennsylvania Office of Attorney General - Medicaid Fraud Control Unit, Pennsylvania Office of Attorney General – Bureau of Narcotic Investigations, United States Postal Inspection Service, U.S. Attorney’s Office – Criminal Division, Civil Division and Asset Forfeiture Unit, Department of Veterans Affairs-Office of Inspector General, Food and Drug Administration-Office of Criminal Investigations, U.S. Office of Personnel Management – Office of Inspector General and the Pennsylvania Bureau of Licensing.

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U.S. military communities in Washington, D.C., San Diego, and San Antonio are among the first in the Department of Defense to receive the COVID-19 vaccine Dec. 14 as part of the DOD’s initial distribution plan.

Walter Reed National Military Medical Center (WRNMMC) in Bethesda, Maryland, started vaccinating select medical staff for COVID-19 Monday, with acting Secretary of Defense Christopher Miller on hand to witness the initial shots and receive one himself.

"This is a very important day, not just for the Department of Defense, but for our nation," Miller said before getting his vaccination.

Seven months after President Donald Trump announced Operation Warp Speed and the goal to deliver a vaccine by January 2021, "today... the very first Americans are being inoculated by a safe and highly effective vaccine," Miller said.

"Our service members, DOD civilians, and their families have demonstrated remarkable endurance and sacrifice throughout the pandemic," he added. "We know that our collective sacrifice would accelerate the path to a cure and save lives."

Miller said that because of the DOD's precision logistics, "the first shipments of vaccines are arriving securely at hundreds of distribution sites around the country as we speak," he added.

In addition to WRNMMC, Naval Medical Center San Diego in California and the Air Force's 59th Medical Wing in San Antonio, Texas, also received their first shipment Monday and expect to begin vaccinations Tuesday.

These are the first of an initial 16 DOD sites to receive authorized COVID-19 vaccines as part of the DOD’s phased approach to distribute and administer COVID-19 vaccines.

Last week, the Pentagon outlined the DOD's plan to vaccinate its population of approximately 11.1 million.

“Our goal is to be transparent with the force about what is happening and to encourage our personnel to use the vaccine,” said Pentagon Spokesman Jonathan Hoffman during a DOD press briefing last week with Assistant Secretary of Defense for Health Affairs Thomas McCaffery and Army Lt. Gen. Ronald Place, Defense Health Agency director.

McCaffery and Place said the phased, standardized, and coordinated strategy for prioritizing, distributing, and administering COVID-19 vaccines was developed in collaboration with Operation Warp Speed, the Centers for Disease Control and Prevention (CDC), and the DOD’s COVID Task Force assessment of unique mission requirements.

It “will provide the COVID vaccine to DOD uniformed service members, both active and selective reserve components, including members of the National Guard, dependents, retirees, civilian employees, and select DOD contract personnel as authorized in accordance with DOD policy,” added McCaffery.

Priority populations and selected locations

Based on the limited initial availability, DOD is slated to receive an allotment of just under 44,000 doses of the Pfizer vaccine for this first week, which will be distributed in proportion to population size of selected sites. The Pfizer vaccine was approved for emergency use authorization Dec. 11 by the U.S. Food and Drug Administration.

The DOD locations were selected because they meet several unique criteria that best support the initial distribution and administration plan, according to McCaffery. For example, all 16 locations meet the unique supply-chain requirements for initial vaccines, such as the capability for ultra-cold storage.

Additionally, all sites serve a sizable DOD population with priority personnel across all military services who will receive the vaccine before other members of the healthy DOD population — including health care providers and support personnel, residents and staff of DOD long-term care facilities, other essential workers such as emergency responders and security personnel, and high-risk beneficiaries. And they all have sufficient medical personnel to administer the vaccines and monitor recipients.

Vaccine safety

Even though the vaccine cannot be mandated under the terms of the emergency use authorization, the department is strongly encouraging everyone to get it to “protect yourselves, your families, your shipmates, your wingmen, your battle buddies, and your communities,” said Place. “The preliminary data on the safety and effectiveness of the two vaccine candidates is highly encouraging.”

As with most vaccines, Place explained, there is a chance some recipients will experience slight adverse effects, such as arm soreness, fatigue, and fever.

“The department will be fully transparent about any adverse effects that are reported and share this information with the CDC,” said the DHA director. However, as a physician, he advised everyone to get the vaccine. “The risk of these vaccines, from what we know, is much less than the risk of the actual disease process.”

Vaccines are only available after they are demonstrated to be safe and effective in phase 3 clinical trials, have been authorized by FDA, and have been manufactured and distributed safely and securely. Additionally, the DOD has decades of experience with conducting global vaccine programs — whether it’s annual flu campaigns or protection against novel diseases around the world.

“We vaccinate millions of our service members and families and retirees of every age every year, and we have systems in place to monitor the health of everyone who receives a vaccine,” Place said.

Mitigation during phased distribution

As a result of the gradual approach, DOD will continue to distribute vaccines in a phased format, “adding additional prioritized personnel and additional prioritized locations until allocations of the vaccine reach 60 percent of our DOD, roughly 11.1 million personnel," explained McCaffery.

Once the 60 percent threshold is reached, DOD anticipates vaccine manufacturing rates to support full-scale, unrestricted vaccine distribution to department personnel. At that point, DOD intends to distribute the vaccine in the same way it conducts its annual flu vaccine program.

“I’m extremely confident the department’s plan … provides a very clear roadmap to protect our entire DOD population across the globe against the pandemic,” said McCaffery. “This has been a tough year for all Americans, and I’m inspired by the perseverance and commitment of the men and women of the department and the Military Health System. Together we’re working as a team to protect all entrusted to our care.”

DOD health officials stressed the need to continue wearing appropriate face coverings, practice physical distancing, wash hands, and following local and installation force health protection guidelines until a large portion of the DOD population is vaccinated.

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Fraudulent orders included knee brace for leg amputee

AUGUSTA, GA: A Rockdale County, Ga., nurse practitioner faces substantial time in federal prison after a jury found her guilty of health care fraud, aggravated identity theft, and other counts in a multimillion-dollar telemedicine fraud scheme.

Sherley L. Beaufils, 43, of Conyers, Ga., was convicted after a two-day trial on charges of an illegal kickback conspiracy, and five counts each of Health Care Fraud, False Statements Related to Health Care, and Aggravated Identity Theft, said David H. Estes, U.S. Attorney for the Southern District of Georgia. Conviction on the charges subjects Beaufils to a possible statutory sentence of up to 10 years in prison on each count of Health Care Fraud, two years on each count of Aggravated Identity Theft, and five years in prison on all other counts, along with substantial fines and penalties, followed by a period of supervised release upon completion of any prison term. There is no parole in the federal system.

“Indicted in the Southern District as part of the nationwide Operation Brace Yourself initiative targeting healthcare fraud, Sherley Beaufils profited by signing unnecessary orders for orthotic braces for patients she never examined or spoke to,” said U.S. Attorney Estes. “Her greed was her undoing – and she is now being held accountable for targeting the elderly with her serial fraud.”

As described in court documents and testimony, Beaufils, as a nurse practitioner, facilitated orders for more than 3,000 orthotic braces that generated more than $3 million in fraudulent or excessive charges to Medicare. Co-conspirators captured the identities of senior citizens, identified through a telemarketing scheme, and bundled that information as “leads.”

Beaufils then signed her name to fake medical records, in which she falsely claimed she provided examinations of those patients, and then created orders for orthotic braces for patients she never met or spoke with – including a knee brace for an amputee, and a back brace for a recently deceased patient – and other durable medical equipment, in exchange for money. Beaufils’s fraudulent orders were then sold to companies that would generate reimbursement from Medicare.

Beaufils was found not guilty at trial of one additional charge of conspiracy.

“Today, this defendant found out what health care providers who defraud Medicare are finding out all over America: fraudsters will be held accountable for their greed-fueled fraud schemes,” said Special Agent in Charge Tamala E. Miles of the Department of Health and Human Services Office of Inspector General. “Our investigators will continue to work closely with our state and federal law enforcement partners to protect federal health care programs from such scams.”

“The level of greed shown by Beaufils in this case is shocking, as she lined her pockets at the expense of American taxpayers and government funded healthcare programs,” said Philip Wislar, Acting Special Agent in Charge of FBI Atlanta. “Health care costs are driven up when doctors and staff bill for unnecessary and incomplete services, and the FBI and our partners will use every resource necessary to put a stop to it.”

The case was investigated by the FBI and the U.S. Department of Health and Human Services Office of Inspector General, and prosecuted for the United States by Assistant U.S. Attorneys Jonathan A. Porter and Patricia G. Rhodes.

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CAMDEN, N.J. – A federal grand jury today returned a five-count indictment charging a Gloucester County, New Jersey, man with defrauding his employer’s health insurance plan out of more than $4 million by submitting fraudulent claims for medically unnecessary compounded medications, Acting U.S. Attorney Rachael A. Honig announced today.

Christopher Gualtieri, 48, of Franklinville, New Jersey, is charged with conspiracy to commit health care fraud and mail fraud and individual acts of mail fraud. Gualtieri was also charged with making false statements to federal agents during the investigation, as well as preparing and filling fraudulent oxycodone prescriptions. Gualtieri is scheduled to appear today by videoconference before U.S. Magistrate Judge Sharon A. King. The case is assigned to U.S. District Judge Robert B. Kugler in Camden.

According to the indictment:

Compounded medications are specialty medications mixed by a pharmacist to meet the specific medical needs of an individual patient. Compounded drugs can be properly prescribed when a physician determines that an FDA-approved medication does not meet the health needs of a particular patient, such as if a patient is allergic to a dye or other ingredient.

Gualtieri and others learned that certain compound medication prescriptions – including vitamins, scar creams, pain creams, and sunscreens – were reimbursed by their health insurance plan for up to thousands of dollars for a one-month supply. Gualtieri recruited co-workers who were covered by their employer’s self-funded health insurance plan to agree to receive medically unnecessary compounded medications for themselves and their family members. Gualtieri and others caused the submission of fraudulent prescriptions to compounding pharmacies, which filled the prescriptions and billed the health insurance plan’s pharmacy benefits administrator. The pharmacy benefits administrator paid the compounding pharmacies more than $4 million for compounded medications arranged by Gualtieri and two conspirators for themselves, their dependents, and other family members. Gualtieri received a portion of the amount paid by the pharmacy benefits administrator to the compounding pharmacies. Gualtieri then paid cash and other remuneration to his conspirators for their participation in the scheme. When questioned by special agents of the FBI, Gualtieri falsely denied recruiting others to receive compounded medications and falsely denied paying cash to others for their participation in the scheme.

During the same time period as the conspiracy involving compounded medications, Gualtieri also prepared and filled fraudulent prescriptions for oxycodone for himself and a family member.

Gualtieri faces a maximum penalty on the conspiracy and mail fraud counts of 20 years in prison, a maximum penalty on the false statements count of five years in prison, and a maximum penalty on the obtaining drugs by fraud count of four years in prison. He also faces a fine on each count of up to $250,000 or twice the gross gain or gross loss from the offense, whichever is greatest.

Acting U.S. Attorney Honig credited agents of the FBI, Philadelphia Field Office, Health Care Fraud Task Force, under the direction of Acting Special Agent in Charge Bradley S. Benavides, and task force members from the Pennsylvania Attorney General’s Office, Department of Health and Human Services – Office of Inspector General, and the Philadelphia Police Department, as well as diversion investigators of the Drug Enforcement Administration, New Jersey Division, Camden Resident Office, under the direction of Special Agent in Charge Susan A. Gibson, with the investigation leading to the indictment. Acting U.S. Attorney Honig also thanked U.S. Postal Service – Office of Inspector General, for their assistance in the investigation.

The government is represented by Assistant U.S. Attorney Jeffrey Bender of the U.S. Attorney’s Office in Camden.

The charges and allegations contained in the indictment are merely accusations, and the defendant is presumed innocent unless and until proven guilty.

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Over the past several years, the Government Accountability Office (GAO) added VA health care and acquisition management to its High-Risk List. Addressing longstanding challenges requires sustained leadership and strong management and would help ensure veterans receive the care and benefits they deserve.

H.R. 693, the VACANT Act, would require the VA Secretary to appoint a VA medical center director as acting director after detailing that director to a different position within the Department. The individual appointed as acting director would be afforded all of the authority and responsibilities of the detailed director.

DAV supports H.R. 693, in accordance with DAV Resolution No. 056, as it would improve accountability to sustain needed leadership to ensure the VA health care system runs seamlessly during a period of transition and that veterans’ continuity of care and benefits are not disrupted.

TAKE ACTION

SAN ANTONIO – Three separate healthcare providers within the Western District of Texas have agreed to pay a collective $1,056,340.50 to resolve liability under the False Claims Act for the alleged improper billing of electro-acupuncture devices.

These providers – Ledger Foot & Ankle, P.A of Harker Heights, Superior Physical Medicine of Round Rock and Precision Spine and Pain Management of San Antonio – billed Medicare and/or TRICARE for the implantation of neuro-stimulators, a surgical procedure that usually requires an operating room and is reimbursable by federal healthcare programs. In these matters, the procedure billed actually involved a non-surgical, non-invasive application of the devices that is non-reimbursable by federal healthcare programs.

Between February 2018 and January 2020, Dr. Harold Ledger, DPM, of Harker Heights, through his practice, Ledger Foot & Ankle, P.A., billed Medicare for the application of ANSiStim devices to beneficiaries as though they were implantable neurostimulators. Certain Medicare beneficiaries were identified as also having TRICARE benefits that were further billed to the program as the secondary insurer. Dr. Ledger will pay a total of $535,000.00 to resolve his liability under the False Claims Act.

Between December 2016 and September 2018, SPR Medical Group (formerly known as Atlas Medical Group), d/b/a Superior Physical Medicine, (“Superior”) billed Medicare for the application of ANSiStim and STIVAX devices as though they were implantable neurostimulators. Following a Medicare audit of two neurostimulation procedures, Superior initiated a full repayment of the Medicare funds received for those two claims and conducted an internal audit of all claims. Superior self-disclosed claims improperly billed and has agreed to pay a total of $338,150.50 to resolve any potential liability under the False Claims Act.

Between March 1 and April 2019, Dr. Yurii Borshch, through his practice Precision Spine and Pain Management, billed Medicare for the application of ANSiStim devices to beneficiaries as though they were implantable neurostimulators. During the pendency of the investigation and settlement negotiations, Dr. Borshch initiated refund payments to Medicare for the identified claims and paid a total of $183,190.00 to resolve potential liability under the False Claims Act.

The settled civil claims are allegations only and do not constitute admissions of liability by any of the identified practitioners.

These matters were investigated by the U.S. Department of Health and Human Services Office of the Inspector General. All three settlements were negotiated on behalf of the government by Assistant U.S. Attorney Erin M. Van De Walle.

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The Honoring our PACT Act, will improve health care and benefits for veterans exposed to toxic substances. This comprehensive bill will address herbicide, radiation, and burn pits.

A procedural issue required Congress to amend and pass the PACT Act again. The House has done its job and passed the bill with bipartisan support. Every day this bill is delayed means another day a veteran could get sick and die. The Senate must stop any further delays and immediately pass the Honoring our PACT Act.

Contact your Senators and tell them no more delays, they must bring the Honoring our PACT Act to the floor immediately and vote YES.

TAKE ACTION

WASHINGTON – Folashade Adufe Horne, 51, of Laurel, Maryland, pled guilty on February 17, 2021 in federal court to defrauding the D.C. Medicaid program out of more than $370,000.

The announcement was made by Acting U.S. Attorney Michael R. Sherwin; James A. Dawson, Special Agent in Charge, FBI Washington Field Office, Criminal Division; Maureen R. Dixon, Special Agent in Charge of the U.S. Department of Health and Human Services’ Office of Inspector General for the region that includes Washington, D.C.; and Daniel W. Lucas, Inspector General for the District of Columbia.

Horne pled guilty to health care fraud in the United States District Court for the District of Columbia. The charge carries a statutory maximum of 10 years in prison and financial penalties. Under federal sentencing guidelines, Horne faces a likely recommended sentence of between 18 and 24 months in prison. The Honorable Reggie B. Walton took the plea and scheduled sentencing for May 12, 2021.

At various times between January 2014 and June 2020, Horne was employed by four different home health agencies to serve as a personal care aide for D.C. Medicaid beneficiaries. Horne also was employed full-time by Howard University during this same period. The home health agencies employed Horne to assist Medicaid beneficiaries in performing activities of daily living, such as getting in and out of bed, bathing, dressing, and eating. Horne was supposed to document the care she provided to the Medicaid beneficiaries on timesheets and then submit the timesheets to the home health agencies, which would in turn bill Medicaid for the services that she rendered.

Horne acknowledged that between January 2014 and June 2020, she caused the D.C. Medicaid Program to issue payments totaling $373,564 for services that she did not render. As part of her fraud scheme, she submitted false timesheets to different home health agencies purporting that she provided personal care aide services that she did not provide. She claimed she provided such services during times when she actually was working her shift as a full-time employee at Howard University Hospital. She claimed to work more than twenty hours in a given day on more than 200 occasions, including 28 days when she asserted that she provided 32 hours of PCA services. She also claimed to provide personal care aide services in the District of Columbia on days when she was not even in the United States.

The FBI, the Department of Health and Human Services’ Office of Inspector General, the District of Columbia’s Office of the Inspector General’s Medicaid Fraud Control Unit, and the U.S. Attorney’s Office are committed to investigating and prosecuting individuals who defraud the D.C. Medicaid program. Since October 2019, six former personal care aides have been sentenced in U.S. District Court for defrauding Medicaid. Cases against two other personal care aides remain outstanding.

The government counts on the public for tips and assistance in helping stop health care fraud. If you have information about individuals committing health care fraud, please call the Department of Health and Human Services’ Office of Inspector General hotline at (800) HHS‑TIPS [(800) 447-8477].

Assistant U.S. Attorney Kondi Kleinman of the Fraud Section is prosecuting the case.

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HR 1476, PFC Joseph P. Dwyer Peer Support Program Act, will authorize the Secretary of Veterans Affairs to make grants to State and local entities and Non-Governmental Organizations (NGO) to carry out peer-to-peer mental health programs. As you know veteran suicide has reached epidemic level. We are losing thousands of veterans to suicide every year. In most cases mental health plays a role in these tragic deaths. The VA is not able to provide needed services on the local level to arrest this trend. They lack both the expertise and the resources to expand into local communities and tribal areas. This bill will make State and local governments and NGOs allies in the battle against veteran suicide.

TAKE ACTION

HR 6659 and S 3541, the Health Care for Burn Pit Veterans Acts, will provide health care and benefits to Veterans suffering from the effects of toxic exposure. It is a cost of war that must be paid, and it is past time for Congress to deliver on this promise. It is consistent with the pending COST of War Act, won’t negatively impact VA’s delivery of care or benefits to Veterans, and can garner enough bipartisan support to get it all the way to the President’s desk— making it our best chance at ensuring all past, present, and future generations get the care and benefits they earned.

TAKE ACTION

PITTSBURGH - A resident of Louisville, Kentucky, pleaded guilty in federal court to a charge of health care fraud, Acting United States Attorney Stephen R. Kaufman announced today.

Varanise C. Booker, 66, pleaded guilty to one count before Senior United States District Judge David S. Cercone.

In connection with her guilty plea, the defendant admitted that she was a licensed psychiatrist who operated a medical practice, Family and Children Behavioral Health Services, in Louisville, Kentucky. Between approximately October 2011 and August 2013, the defendant further admitted that she referred patients for drug testing and related services performed by Universal Oral Fluid Labs (“UOFL”), a clinical drug testing and drug screening laboratory located in Greensburg, Pennsylvania. The court was further advised that the defendant engaged in health care fraud by causing UOFL to bill the Kentucky Medicaid program for testing based on referrals that were outside the ordinary course of professional practice and not for a legitimate medical purpose. Specifically, the defendant acknowledged that she did not document a legitimate justification for ordering certain drug tests and services, failed to document the results of certain drug tests and services performed by UOFL in her medical files, and failed to address the results of certain drug tests and services in the treatment of her patients. The defendant further admitted that she caused UOFL to pay her a certain portion of the reimbursements the laboratory received from Kentucky Medicaid in connection with her referral of unlawful drug tests and related services. As a result, the defendant caused losses to Kentucky Medicaid of more than $15,000 but not more than $40,000.

Judge Cercone scheduled sentencing for 11:30 a.m. on Feb. 10, 2022. The law provides for a total sentence of not more than 10 years in prison, a fine of $250,000, or both. Under the Federal Sentencing Guidelines, the actual sentence imposed is based upon the seriousness of the offense and the prior criminal history, if any, of the defendant.

Assistant United States Attorney Eric G. Olshan is prosecuting this case on behalf of the government.

The Federal Bureau of Investigation, Health and Human Services Office of Inspector General, Internal Revenue Service - Criminal Investigation, and Pennsylvania Office of Attorney General Medicaid Fraud Control Section conducted the investigation that led to the prosecution of Booker.

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Our disabled Veterans are grossly under compensated. They've been asking various Congresses and Administrations for fair and adequate compensation since the end of World War I in 1918. That was a 103 years ago.

In 2022, a totally disabled Veteran with no dependents is compensated at the ridiculous rate of $39,984.72 dollars annually. The National Average Wage Index for 2020 was $55,628.60 dollars per annum and the median income for 2020 was $67,521.00. The per capita GDP in 2020 was $63,416.00 dollars, among the highest in the world.

This compensation abuse of disabled Veterans is now a national security problem.

Once our youth fully understand that should they enlist in the armed forces and subsequently be seriously injured or sickened in the line of duty then they are looking at a lifetime of near poverty and this realization among our young people will cause the armed forces to collapse quickly. We have no right to expect our youth to make a sacrifice like this so that our elites can evade a fair level of taxation.

Act now.

— Peter Harkness, Wilmington

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Tampa, FL – United States Attorney Maria Chapa Lopez announces that Kelly Wolfe (49, Indian Rocks Beach) has pleaded guilty to conspiracy to commit health care fraud and filing a false tax return. She faces a maximum penalty of 13 years in federal prison. A sentencing date has not yet been set.

In addition to her criminal charges, Wolfe and her company, Regency, Inc. (“Regency”) have agreed to pay up to $20,332,516, to resolve allegations that Wolfe and Regency violated the False Claims Act in a number of ways, including falsifying documentation in order to fraudulently establish durable medical equipment (“DME”) corporations to bill for medically unnecessary DME equipment, and engaging in improper marketing practices that violate the Anti-Kickback Statute. The civil settlement amount is based on Wolfe and Regency’s ability to pay.

According to court documents, Wolfe and her conspirators used Regency to establish dozens of DME supply companies—or, rather, DME fronts—using trickery and deception. The scheme involved placing the DME fronts in the names of straw owners. By concealing the true ownership of the fronts, Wolfe’s conspirators secretly gained control of multiple companies. With such control, they collectively submitted well over $400 million in illegal DME claims to Medicare and CHAMPVA (i.e., the Civilian Health and Medical Program of the Department of Veterans). The conspirators relied on the guise of “telemedicine” to explain the unusually high volume of claims, when, in fact, they had simply bribed doctors to approve them. Almost always, the doctors had no interaction, including telehealth interaction, with the beneficiaries. Wolfe further admitted that, for tax year 2017, she had purchased numerous personal items and services using Regency’s funds. Rather than properly report this as income to the Internal Revenue Service, Wolfe falsely classified her personal spending as purported business expenditures.

This prosecution, arising out of the nationwide “Operation Brace Yourself” takedown, involves one of the largest health care fraud schemes in United States history. The Middle District of Florida is playing a significant role in these historic and nationwide enforcement actions. Collaborative efforts among federal, state, and local partners have resulted in criminal charges against 12 defendants in the MDFL.

“The Department is committed to ensuring that federal health care program providers do not place their own financial gain over patients’ clinical needs,” said Acting Assistant Attorney General Brian Boynton of the Department of Justice’s Civil Division. “When medical professionals and companies knowingly commit fraud to maximize their profits, we will hold them accountable for their unlawful conduct.”

“Fraud and deceit in our nation’s healthcare system is not only unacceptable, it is illegal,” said U.S. Attorney Maria Chapa Lopez for the Middle District of Florida. “The U.S. Attorney’s Office will continue to aggressively work with our investigative partners in rooting out these illicit practices to ensure that patients receive the optimum care they deserve.”

“This pernicious telefraud scheme’s ambitions were cut short by the exceptional partnership of our law enforcement partners” said Special Agent in Charge Omar Pérez Aybar of the U.S. Department of Health and Human Services Office of Inspector General. “This guilty plea and the forfeiture of tens of millions of dollars back to the U.S. Treasury show our determination to stop such damaging fraud schemes and to bring fraudsters to justice.”

"The FBI is laser-focused on exposing those who cheat our government healthcare programs," said Special Agent in Charge of the FBI Tampa Division Michael McPherson. "American taxpayers can be assured the FBI and its law enforcement partners are working vigorously to protect federally funded healthcare programs from deception and greed."

“Honest and law-abiding citizens are fed up with the likes of those who use deceit and fraud to line their pockets," stated Special Agent in Charge Brian Payne of IRS Criminal Investigation. "Fleecing the health care industry effectively robs us all, and tax fraud undermines the integrity of our nation’s tax system. Those who engage in these swindles should know they will not go undetected and will be held accountable."

“The VA OIG’s continued oversight of CHAMPVA, which provides community care to family members of disabled Veterans, is one of the agency’s highest priorities because it safeguards the integrity of VA’s health care programs,” stated David Spilker, Special Agent in Charge at the Department of Veterans Affairs Office of Inspector General (VA OIG). “As detailed in the charging documents, the defendant’s criminal actions resulted in a massive fraud being committed against both CHAMPVA and Medicare, ultimately impacting the beneficiaries of those programs. The VA OIG commends the extensive cooperation between our law enforcement partners in this important investigation.”

This case is being prosecuted criminally by Assistant United States Attorneys Kristen Fiore and James Muench, and pursued civilly by Assistant United States Attorney Carolyn B. Tapie and Department of Justice, Civil Division, Commercial Litigation Branch Trial Attorney Daniel A. Schiffer, with assistance from the Department of Health and Human Services – Office of Inspector General, the FBI, the Department of Veterans Affairs – Office of Inspector General, and the Internal Revenue Service – Criminal Investigation. The United States previously obtained an emergency temporary restraining order and preliminary injunction enjoining the conduct and assets of Wolfe, Regency, and several of their co-conspirators, in a civil injunctive action prosecuted by Assistant United States Attorneys Carolyn B. Tapie and Sean P. Keefe. The injunctive action is captioned United States v. Regency, Inc., et al., No. 8:19-cv-803-T-33AEP.

The civil settlement includes the resolution of claims brought under the qui tam or whistleblower provisions of the False Claims Act against Wolfe and Regency by Condra Albright, a former Regency employee. As a result of the settlement, Albright will receive 23% of the civil recovery as her statutory reward. Under the qui tam provisions of the False Claims Act, a private party can file an action on behalf of the United States and receive a portion of the settlement if the government takes over the case and reaches a monetary agreement with the defendant. The claims resolved by the settlement are allegations only, and there has been no determination of liability.

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A federal grand jury in New Orleans, Louisiana, returned an indictment today charging a Louisiana physician for his role in distributing over 1,200,000 doses of Schedule II controlled substances, including oxycodone and morphine, outside the scope of professional practice and not for a legitimate medical purpose, and for maintaining his clinic for the purpose of illegally distributing controlled substances. Today’s indictment also charges the physician with defrauding health care benefit programs, including Medicare, Medicaid, and Blue Cross and Blue Shield of Louisiana, of more than $5,100,000, given that the opioid prescriptions were filled using health insurance benefits.

According to court documents, Adrian Dexter Talbot, M.D., 55, of Slidell, owned and operated a medical clinic located in Slidell that accepted cash payments from individuals seeking prescriptions for Schedule II controlled substances. In 2015, Talbot took a full-time job in Pineville, Louisiana, and although he was no longer physically present at the Slidell clinic, he pre-signed prescriptions to be distributed to individuals there without seeing or examining those individuals. In 2016, Talbot hired another practitioner who also pre-signed prescriptions to be distributed in the same manner at the Slidell clinic. With Talbot’s knowledge, individuals were filling their prescriptions that were issued outside the scope of professional practice and not for a legitimate medical purpose using their insurance benefits, thereby causing health care benefit programs to be fraudulently billed for filling prescriptions that were written without an appropriate patient examination or determination of medical necessity for the prescription.

Talbot is charged with one count each of conspiracy to unlawfully distribute and dispense controlled substances, maintaining a drug-involved premises and conspiracy to commit health care fraud, as well as four counts of unlawfully distributing and dispensing controlled substances. The defendant is scheduled for his initial court appearance Sept. 10 before U.S. Magistrate Judge Michael B. North of the U.S. District Court for the Eastern District of Louisiana. If convicted, he faces a maximum penalty of 10 years for conspiracy to commit health care fraud and 20 years each for all other counts. A federal district court judge will determine any sentence after considering the U.S. Sentencing Guidelines and other statutory factors.

Assistant Attorney General Kenneth A. Polite Jr. of the Justice Department’s Criminal Division; U.S. Attorney Duane A. Evans for the Eastern District of Louisiana; Special Agent in Charge Douglas A. Williams Jr. of the FBI’s New Orleans Field Office; Special Agent in Charge Miranda Bennett of the Department of Health and Human Services, Office of Inspector General (HHS-OIG); and Special Agent in Charge Jeffrey Breen for the Department of Veterans Affairs, Office of Inspector General (VA-OIG) made the announcement.

The FBI, HHS-OIG, VA-OIG, and the Louisiana Office of the Attorney General’s Medicaid Fraud Control Unit are investigating the case.

Trial Attorney Sara E. Porter of the Criminal Division’s Fraud Section and Assistant U.S. Attorney David Howard Sinkman of the Eastern District of Louisiana are prosecuting the case.

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Dr. Feng Qin Agrees to Pay $800,000, Admits Misconduct, and Receives Four-Year Ban from Participating in Federal Healthcare Programs

Audrey Strauss, the United States Attorney for the Southern District of New York, and Scott Lampert, Special Agent in Charge of the U.S. Department of Health and Human Services, Office of Inspector General’s (“HHS-OIG”) New York Region, announced today that the civil and criminal healthcare fraud cases against FENG QIN, M.D. (“QIN”), a vascular surgeon, and his medical practice QIN MEDICAL P.C. (“QIN MEDICAL”) have been resolved. QIN, who practiced in Lower Manhattan and Far Rockaway, Queens, was criminally charged in December 2018 with fraudulently billing Medicare for vascular surgery procedures performed on end-stage renal disease (“ESRD”) patients that were not medically reasonable and necessary or covered under Medicare rules; the United States also filed a civil healthcare fraud complaint against QIN and QIN MEDICAL in December 2018.

Under the civil settlement approved today by U.S. District Judge Laura Taylor Swain, QIN and QIN MEDICAL agreed to a pay $783,200 to the United States. The State of New York is expected soon to enter into an additional settlement with defendants in the amount of $16,800, for a total recovery of $800,000. The amount is based on the Office’s assessment of the defendants’ ability to pay based on the financial information they provided. As part of the settlement, QIN and QIN MEDICAL admitted and accepted responsibility for conduct alleged by the Government in its civil complaint as further described below. QIN previously paid $150,000 to settle a prior civil fraud lawsuit filed against him and his previous employer for engaging in fraudulent billing practices during the time period 2010 through 2012.

QIN also entered into a Voluntary Exclusion Agreement with HHS-OIG, which prohibits him from participating in Medicare and other federal healthcare programs for four years. This is in addition to the more than two years he has been so excluded since his arrest, as a condition of his bail. The Government has agreed to defer QIN’s criminal prosecution for a period of one year, after which time it will seek to dismiss the charges if QIN abides by the terms of the deferred prosecution agreement.  

Manhattan U.S. Attorney Audrey Strauss said: “For several years, Dr. Qin performed interventional vascular procedures on patients with end-stage renal disease without any documented clinical justification. As a repeat offender, Dr. Qin now faces a lengthy suspension from participating in federal healthcare programs and must make a hefty monetary payment. This Office will continue to hold unscrupulous medical providers accountable when they perform and bill the Government for medically unnecessary procedures.”

HHS-OIG Special Agent in Charge Scott Lampert said: “By billing Medicare for medically unnecessary procedures, Dr. Qin needlessly compromised patient care and victimized taxpayers. Our agency will continue to hold medical professionals accountable, while protecting the federal health care programs intended for those that depend on them for critical services.”

According to the indictment and the Government’s civil complaint:

Patients with ESRD who are receiving dialysis may require vascular access surgical procedures, such as fistulagrams, where dye is injected into the patient’s vein or artery to visualize blood flow, and percutaneous transluminal angioplasties, in which wires and balloons are inserted into blood vessels that have narrowed in order to restore blood flow. However, as Medicare billing guidelines made clear, it is not reasonable and necessary for physicians to bill the program for fistulagrams and angioplasties unless the patient has specific and documented clinical problems, such as significant difficulty receiving dialysis properly.

The patients at QIN’s medical practice primarily consisted of ESRD patients undergoing dialysis treatment. During the relevant period, from 2015 to 2016, QIN routinely scheduled patients for fistulagrams and angioplasties three months in advance, and performed fistulagrams and angioplasties on these patients as a matter of routine, regardless of whether there was a justifiable clinical reason to do so. Furthermore, on multiple occasions he misrepresented the medical conditions of patients in their medical records to make it seem as if they suffered from symptoms that would warrant the procedures when they did not. QIN MEDICAL then unlawfully billed and received payment from Medicare for these procedures, which were excluded from Medicare coverage, as QIN knew.

As part of the civil settlement, QIN and QIN MEDICAL admit, acknowledge, and accept responsibility for the following conduct:

• QIN often routinely scheduled, and actually saw, ESRD patients approximately every three months, regardless of their medical need.

• QIN treated many of his ESRD patients with fistulagrams and angioplasties. The symptoms documented in the medical records, including the records of the dialysis center and the treating nephrologist, were insufficient to justify these treatments for numerous ESRD patients.

• QIN knew that in the absence of a documented clinical justification, Medicare would not pay for fistulagrams or angioplasties. Nevertheless on numerous occasions, QIN MEDICAL sought and received reimbursement from Medicare for these treatments without the required documented clinical justification.
• The allegations of fraud stated in the civil complaint were first brought to the attention of federal law enforcement by a whistleblower who filed a lawsuit under the False Claims Act.

The criminal case is being handled by the Office’s General Crimes Unit. Assistant United States Attorneys Jean-David Barnea, Michael Krouse, and Alexander Li are in charge of the criminal prosecution. The civil case is being handled by the Office’s Civil Frauds Unit, and Assistant United States Attorney Barnea is in charge of the matter.

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There are a variety of formal and informal methods used to help medical officers advance throughout their careers, and some, of course, are better than others.

But Navy Capt. Barry Adams, commanding officer, Navy Medical Leader & Professional Development Command (NML&PDC), said “none of the new models adequately replace the ability to identify someone within your organization and just spontaneously ask them important career questions – ‘What should I do about this or that.’”

NML&PDC, based in Bethesda, Maryland, is responsible for professional development and training programs affecting more than 3,000 students annually through a portfolio of residence courses, professional workshops, distance education and administrative management of multiple pipeline talent management programs.

There is a sophisticated and complicated algorithm within some iterations of formal Navy website mentoring programs for assigning junior service members to senior members and allowing potential mentors and mentees to choose and contact each other; however, “such an official mentoring program could not be as effective as desired because it ceases to be the spontaneous and organic relationship we want in mentoring, “Adams said.

The next iteration of Navy mentoring is often framed as a personal coaching tool, which Adams said is more of what medical personnel are looking for throughout their careers.

“This coaching paradigm is the evolving state of the art,” he noted.

Borrowing a page from a corporate playbook, each member would have some form of a Plan of Action & Management document that identifies tasks to be accomplished. It details resources required to accomplish the elements of the plan, any milestones in meeting the tasks and scheduled completion dates.

Many coaching efforts within Navy medicine start with, or include, a standardized personality assessment, such as the Predictive Index, Meyers-Briggs, or Emotional Intelligence (EQI). It then becomes a suite of assessments staggered across a career. “You need someone certified or licensed in each of those assessment tools to conduct the assessment and then coach you,” said Adams, himself a licensed professional coach.

But this mode has its own issues, he suggested. “The problem is this system is astronomically expensive in resources, time and manpower…and doesn’t necessarily cover what people go to a mentor for.”

There are also Career Development Boards (CDBs). “Career Development Boards are a very formal process tasked across Navy medicine by the surgeon general that is fairly consistent across Navy medicine. During your career, everyone is required to do one. It’s a thorough scrub and review of records and performance and your life,” Adams said.

CDBs are a fully functional system across the enterprise now, and the NML&PDC is actively pursuing a contract to fully automate the CDB process for officers as currently already happens for enlisted sailors. This automation should help maximize consistency and reporting across the enterprise.

“CDBs are a bit closer to mentoring,” Adams said. “It’s a very fixed process, talking to your peers and supervisors, and getting good, solid and assistive scrutiny – not one-on-one mentoring, but a strong mentoring teamwork.”

“CDBs are very labor intensive, but we’re very proud of the program, which is pretty robust,” Adams said. “It comes as close as we’ve been in getting every single Navy medical service member through an effective career development event…but it’s not the same as that personalized sage advice from a mentor chosen by the member.”

At the Uniformed Services University (USU) in Bethesda, Maryland, mentorship is an integral part of all students’ learning and their development into full-fledged medical doctors.

“We look to have a variety of informal and formal opportunities for students from different services to have exposure to individuals who are clinical experts across their careers,” said Air Force Maj. Ryan Landoll, a clinical psychologist and the USU assistant dean for preclinical sciences. “We think these mentors provide inspiration, knowledge, perspective and support.”

Entering students are assigned an officer sponsor for peer mentoring. They are also divided into “fire teams,” groups of four students that intentionally balance diversity in thought, background, experience and service, Landoll explained. These sponsorships and fire teams last through the full 18 months of preclinical studies and through the full course of study at USU. Additionally, students are supported in academics, career and well-being by the Office of Student Affairs.

With the class of 2021, USU is piloting an academic coaching model where there will be regular meetings with faculty who are outside the student’s evaluation system.

Once students are at Military Medical Training Facilities, they are mentored by preceptors on the wards, Landoll said, adding: “We really support our national faculty though a highly robust faculty development program.”

Because military doctors are relocated so often, Landoll said he “encourages ‘aggressive mentorship’ in the sense that mentees should be active seekers of mentorship with specific physicians in their fields of specialty.”

Mentoring, in its broadest sense, creates prolonged and proven positives that help with officer careers in a high-reliability organization such as Navy medicine.

“Mentorship is not only beneficial for knowledge transfer within Navy medicine, but it also fosters other positive factors such as retention, improved health care delivery and innovation, all the while building better leaders for the future operating environment,” said Navy Rear Adm. Gail Shaffer, deputy chief, Bureau of Medicine and Surgery, and surgery/deputy surgeon general of the Navy.

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NEW ORLEANS – U.S. Attorney Duane A. Evans announced that BENJAMIN TEKIPPE (TEKIPPE), age 37, a resident of New Orleans, Louisiana, was charged on September 30, 2021 with health care fraud, aggravated identity theft, and making a false statement.

According to the Indictment, TEKIPPE was a licensed chiropractor in Louisiana. TEKIPPE owned and operated his own practice, Metairie Chiropractic, located in Metairie, Louisiana, where he purported to provide chiropractic services to patients.

TEKIPPE knowingly participated in a scheme to defraud a health care benefit program, in connection with the delivery of and payment for health care benefits and services.

TEKIPPE submitted, and caused to be submitted, fraudulent claims to health care benefit programs that falsely represented that certain health care services were provided to patients, when TEKIPPE knew that those services were not actually provided.

On various dates in 2019, TEKIPPE submitted, or caused to be submitted, claims for payment which were not provided. In addition, TEKIPPE knowingly used or caused to be used, without lawful authority, a means of identification of another person, specifically insurance members’ unique member identification numbers, to bill for services which were not provided.

On or about July 22, 2020, TEKIPPE did knowingly and willfully make a materially false, fictitious, and fraudulent statement to Special Agents of the United States Department of Health and Human Services Office of Inspector General and the Federal Bureau of Investigation.

If convicted of health care fraud, TEKIPPE faces a possible maximum sentence of 10 years imprisonment and up to three years of supervised release. If convicted of aggravated identity theft, TEKIPPE faces a possible sentence of 2 years of imprisonment to be run consecutively to any other sentence and up to one year of supervised release, . If convicted of making a false statement, TEKIPPE faces a possible maximum sentence of 5 years imprisonment and up to three years of supervised release. For each offense, TEKIPPE faces up to a $250,000 fine and a mandatory $100 special assessment fee.

The case is being investigated by the Federal Bureau of Investigation and The Department of Health and Human Services, Office of Inspector General.

An indictment is merely a charge and the guilt of the defendant must be proven beyond a reasonable doubt.

The prosecution of the case is being handled by Assistant United States Attorney Kathryn McHugh.

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EAST SAINT LOUIS, Ill. – Shomanicka Holly, 36, of East Saint Louis, Illinois, was arraigned in federal court today after a grand jury returned an indictment charging her with three counts of felony health care fraud.

The indictment alleges that Holly served as a personal assistant from 2016 to 2019 for a qualified beneficiary enrolled in the Illinois Department of Human Services Home Services Program. The Home Services Program is a Medicaid program in Illinois that provides personal assistants to Medicaid recipients to assist them with general household activities and personal care. It is designed to reduce Medicaid expenditures by avoiding more expensive institutional care, including

nursing home care.

According to the indictment, Holly submitted false timesheets requesting payment for personal assistant services that she never actually performed because she was working at another job, not caring for the Medicaid recipient. In doing so, Holly allegedly defrauded the program and breached its policies stating that personal assistants “cannot charge [the Home Services Program] for the same hours worked when working another job” and “billing for hours not worked constitutes Medicaid fraud.”

Holly’s case is set for trial on October 4, 2021, at 9:00am, before United States District Judge David W. Dugan in the federal courthouse in East St. Louis. If convicted, Holly faces a maximum penalty of 10 years in prison on each fraud count.

An indictment is a formal charge against a defendant. Under the law, a defendant is presumed to be innocent of a charge until proved guilty beyond a reasonable doubt to the satisfaction of a jury.

This case was investigated by agents of the U.S. Department of Health and Human Services, Office of Inspector General (HHS-OIG) and the Illinois State Police, Medicaid Fraud Control Bureau (MFCB). The case is being prosecuted by Assistant United States Attorney Luke J. Weissler.

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EAST ST. LOUIS, Ill. – Shomanicka Holly, 36, of East Saint Louis, Illinois, pled guilty today to a two-count felony information charging her with health care fraud and making materially false statements on a public housing form.

As part of her plea, Holly admitted to defrauding a government funded health care program by requesting payment for services that she never performed. The Illinois Department of Human Services (“IDHS”) operates a program known as the Personal Assistant program, which pays people to work as personal assistants for qualified disabled individuals. The program, which utilizes federal Medicaid funds, will only pay for work performed while the

disabled individuals are present in their homes.

According to court documents, Holly served as a personal assistant to a qualified disabled person from August 2016 to June 2019. During that time, Holly submitted timesheets requesting payment for providing personal assistant services on dates and times when she was working at another job. In doing so, Holly defrauded the program out of funds by falsely certifying that she was at the disabled person’s home when, in fact, she was on the clock somewhere else.

In addition, Holly pled guilty to a separate charge of making materially false statements on a public housing application. Court documents alleged that Holly received public housing assistance through a program funded by the U.S. Department of Housing and Urban Development (“HUD”).

At her plea hearing, Holly acknowledged that she knowingly failed to disclose on her housing assistance renewal application that another adult resided in her home and earned income. The housing agency relied on this information to allocate its limited resources, including in determining whether Holly was eligible for public housing assistance and the amount of assistance. Holly withheld the information to receive more benefits than she was entitled to.

Health care fraud carries a maximum sentence of ten years in prison. Holly faces up to five years in prison for making a materially false statement on a housing form. She may also be fined up to $250,000 and ordered to pay restitution on each charge.

Sentencing is scheduled for April 13, 2022, at 10:00 a.m. in the federal courthouse in East St. Louis, Illinois.

This case was investigated by agents of the United States Department of Health and Human Services, Office of Inspector General (HHS-OIG), United States Department of Housing and Urban Development, Office of Inspector General (HUD-OIG), and the Illinois State Police, Medicaid Fraud Control Bureau (MFCB).

The case was prosecuted by Assistant United States Attorney Luke J. Weissler.

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Discoveries about health conditions faced by Veterans can lead to better care

Million Veteran Program (MVP) researchers are committed to understanding the relationship between genes and health.

Imagine walking into your VA medical center and receiving screenings and treatments designed just for you. For example, your health care provider knows that you have a gene variant indicating you’re at higher risk for heart disease, so she takes extra care to monitor your blood pressure.

Or your mental health care provider knows that your particular genetic makeup means you’ll be more responsive to one drug to treat depression than another, so he is able to bring you effective treatment faster.

This is what MVP researchers hope to one day achieve for Veterans. It’s one of the largest, richest collections of information about genetics and lifestyle in the world.

More than 900,000 Veterans have joined so far

MVP researchers are committed to understanding the relationship between genes and health. Because of the participation of more than 900,000 Veterans, they have made discoveries around a range of health conditions faced by Veterans including:

• Why people with African ancestry may be more at risk for severe kidney disease if they contract COVID-19.
• How military experience and race might affect breast cancer risk.
• The role of genetics as a risk factor for obesity, diabetes, and abnormal lipid levels—all drivers of heart disease.
• How eating yogurt may be beneficial for your health.

Changing Veteran health care

MVP is committed to using its research findings to improve health and wellness for Veterans by accelerating the medical community’s advancement to personalized health care. The program also hopes to use research to improve treatments by informing the development of new drugs and/or re-purposing existing drugs for other conditions.

Want to improve the future of health for Veterans?

Research improves with every Veteran who joins because each person brings their unique genetic information, lifestyle and military experiences to the program. Researchers especially want to advance understanding of health conditions that impact women and people of African and Hispanic ancestry, as those groups have traditionally been under-represented in research. The more varied MVP’s data, the more discoveries researchers can make.

How do I enroll?

It’s easy to enroll in MVP. You can visit many VA facilities nationwide or enroll from the comfort of your home online at mvp.va.gov. Be assured that MVP is committed to keeping participant information protected. All information collected as a part of MVP is stored in a secure database only available for research purposes.

Learn more about how Million Veteran Program uses Veteran data

Check out the “MVP 101” video to learn more about how the program studies information provided by Veteran participants to make discoveries they hope will one day improve Veteran health.

Make your mark on the future of Veteran health care by joining more than 900,000 enrolled Veterans.

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MISSOULA – A Missoula vascular surgeon who operates vein and surgery centers in Missoula and Kalispell has agreed to pay the federal government $3.7 million to settle alleged False Claims Act violations that he performed medically unnecessary surgeries based on improper techniques and submitted fraudulent bills for payment to federal health care programs, U.S. Attorney Leif M. Johnson said today.

Dr. David Bellamah, and his business, Bellamah Vein & Surgery, PLLC, doing business as Bellamah Vein Center, has entered into a civil settlement agreement with the U.S. Attorney’s Office for the District of Montana, the Department of Health and Human Services Office of Inspector General, the Defense Health Agency, the Department of Veterans Affairs and a third party, Lenore Lezanne. The terms of the settlement agreement require Bellamah and his company to pay a settlement amount of $3,746,324. The settlement agreement resolves a civil complaint alleging violations of the False Claims Act and other common law claims. The civil complaint in intervention was filed today in U.S. District Court for the District of Montana along with a stipulation to dismiss the case.

“This civil settlement resolves claims of using improper techniques and unnecessary medical procedures to create and submit false claims to four federal health care programs. Submitting false claims for unnecessary procedures increases the cost of providing services to people who really need it. Had the United States known the truth, it would not have paid such claims. We will investigate and hold accountable medical providers who try to enrich themselves through false billing to federal health benefit programs. I want to thank our office’s health care fraud investigation team, the Department of Health and Human Services Office of Inspector General and the FBI for their work on this case,” U.S. Attorney Johnson said.

“Performing medically unnecessary surgeries risks the health and wellbeing of patients, compromises the integrity of federal health care programs, and increases the financial burden on taxpayers,” stated Curt L. Muller, Special Agent in Charge with the Department of Health and Human Services, Office of Inspector General. “Working closely with our partners, HHS-OIG will continue to safeguard the integrity of federal health care programs by investigating individuals who seek to exploit them.”

“David Bellamah’s alleged actions violated the oath held sacred by physicians,” said Special Agent in Charge Dennis Rice of the Salt Lake City FBI. “Health care fraud affects all Americans and the FBI remains committed to doing our part to combat it.”

The United States contended in court documents that its civil claims against Bellamah and his company arose from him billing for certain services that were medically unnecessary and based on false medical records from January 1, 2015 through March 31, 2017. Bellamah specializes in the diagnosis and treatment of venous reflux disease and varicose veins.

In March 2018, Lezanne, who was a sonographer formerly employed at Bellamah Vein Center, filed a suit in U.S. District Court against Bellamah Vein and Surgery, Bellamah and others alleging Bellamah received government funds for performing unnecessary venous procedures based on inaccurate medical records. The United States partially intervened in the case.

In its complaint, the United States alleged that Bellamah and staff at Bellamah Vein Center used improper techniques to conduct and analyze ultrasounds and used false ultrasound findings to conduct and bill for medically unreasonable and unnecessary services related to the diagnosis and treatment of venous reflux disease and varicose veins. The government contends that Bellamah submitted false claims to the Department of Health and Human Services’ Medicare and Medicaid programs, the Department of Defense’s TRICARE program and the Department Veterans Affairs’ CHAMPVA program.

The Settlement Agreement directs Bellamah to pay the United States $3,746,324, plus interest if applicable, of which $1,923,861 is restitution and the remaining $1,822,463 is settlement of additional damages. If the settlement amount is paid in full within 21 days of the effective date of the Settlement Agreement, no interest shall be charged. Otherwise, Bellamah shall make payments, plus interest, over five years. Upon receiving the settlement amounts, the United States will pay Lezanne 17 percent of each payment as her share of the settlement.

The Settlement Agreement is neither an admission of liability by Bellamah nor a concession by the United States that its claims are not well founded.

Assistant U.S. Attorney Michael A. Kakuk represented the United States in this matter, which was investigated by office’s health care fraud investigation team, the Department of Health and Human Services Office of Inspector General and the FBI, with additional assistance from the Defense Health Agency and the Department of Veterans Affairs.

PACER case reference. 18-57-M-DLC

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MISSOULA – A Missoula vascular surgeon who operates vein and surgery centers in Missoula and Kalispell has agreed to pay the federal government $3.7 million to settle alleged False Claims Act violations that he performed medically unnecessary surgeries based on improper techniques and submitted fraudulent bills for payment to federal health care programs, U.S. Attorney Leif M. Johnson said today.

Dr. David Bellamah, and his business, Bellamah Vein & Surgery, PLLC, doing business as Bellamah Vein Center, has entered into a civil settlement agreement with the U.S. Attorney’s Office for the District of Montana, the Department of Health and Human Services Office of Inspector General, the Defense Health Agency, the Department of Veterans Affairs and a third party, Lenore Lezanne. The terms of the settlement agreement require Bellamah and his company to pay a settlement amount of $3,746,324. The settlement agreement resolves a civil complaint alleging violations of the False Claims Act and other common law claims. The civil complaint in intervention was filed today in U.S. District Court for the District of Montana along with a stipulation to dismiss the case.

“This civil settlement resolves claims of using improper techniques and unnecessary medical procedures to create and submit false claims to four federal health care programs. Submitting false claims for unnecessary procedures increases the cost of providing services to people who really need it. Had the United States known the truth, it would not have paid such claims. We will investigate and hold accountable medical providers who try to enrich themselves through false billing to federal health benefit programs. I want to thank our office’s health care fraud investigation team, the Department of Health and Human Services Office of Inspector General and the FBI for their work on this case,” U.S. Attorney Johnson said.

“Performing medically unnecessary surgeries risks the health and wellbeing of patients, compromises the integrity of federal health care programs, and increases the financial burden on taxpayers,” stated Curt L. Muller, Special Agent in Charge with the Department of Health and Human Services, Office of Inspector General. “Working closely with our partners, HHS-OIG will continue to safeguard the integrity of federal health care programs by investigating individuals who seek to exploit them.”

“David Bellamah’s alleged actions violated the oath held sacred by physicians,” said Special Agent in Charge Dennis Rice of the Salt Lake City FBI. “Health care fraud affects all Americans and the FBI remains committed to doing our part to combat it.”

The United States contended in court documents that its civil claims against Bellamah and his company arose from him billing for certain services that were medically unnecessary and based on false medical records from January 1, 2015 through March 31, 2017. Bellamah specializes in the diagnosis and treatment of venous reflux disease and varicose veins.

In March 2018, Lezanne, who was a sonographer formerly employed at Bellamah Vein Center, filed a suit in U.S. District Court against Bellamah Vein and Surgery, Bellamah and others alleging Bellamah received government funds for performing unnecessary venous procedures based on inaccurate medical records. The United States partially intervened in the case.

In its complaint, the United States alleged that Bellamah and staff at Bellamah Vein Center used improper techniques to conduct and analyze ultrasounds and used false ultrasound findings to conduct and bill for medically unreasonable and unnecessary services related to the diagnosis and treatment of venous reflux disease and varicose veins. The government contends that Bellamah submitted false claims to the Department of Health and Human Services’ Medicare and Medicaid programs, the Department of Defense’s TRICARE program and the Department Veterans Affairs’ CHAMPVA program.

The Settlement Agreement directs Bellamah to pay the United States $3,746,324, plus interest if applicable, of which $1,923,861 is restitution and the remaining $1,822,463 is settlement of additional damages. If the settlement amount is paid in full within 21 days of the effective date of the Settlement Agreement, no interest shall be charged. Otherwise, Bellamah shall make payments, plus interest, over five years. Upon receiving the settlement amounts, the United States will pay Lezanne 17 percent of each payment as her share of the settlement.

The Settlement Agreement is neither an admission of liability by Bellamah nor a concession by the United States that its claims are not well founded.

Assistant U.S. Attorney Michael A. Kakuk represented the United States in this matter, which was investigated by office’s health care fraud investigation team, the Department of Health and Human Services Office of Inspector General and the FBI, with additional assistance from the Defense Health Agency and the Department of Veterans Affairs Office of Inspector General.

PACER case reference. 18-57-M-DLC

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A study into the immune responses of the two mRNA COVID-19 vaccines found that Moderna’s vaccine created twice as many antibodies as the Pfizer-BioNTech vaccine.

Researchers analyzed the antibody levels of Belgium health care workers after they received both doses of the vaccines, including 688 vaccinated with Moderna and 959 who received the Pfizer shots, in the study published in the Journal of the American Medical Association on Monday.

Among those who had not been previously infected, the Moderna recipients averaged 2,881 units per milliliter, compared to the Pfizer recipients who counted 1,108 units per milliliter.

Participants who previously contracted COVID-19 reported higher antibody levels, raising the overall average among all participants to 3,836 units per milliliter for Moderna and 1,444 units per milliliter for Pfizer.

The antibody levels in those who received Moderna were higher in infected, uninfected and across age categories, according to the study.

The researchers said the difference in antibody levels could potentially be attributed to the higher mRNA content within the Moderna vaccine and the longer interval between the initial and second shots. The second vaccine of Moderna is given four weeks after the first shot, while the Pfizer vaccine is administered three weeks following the initial shot.

The antibody testing was conducted before vaccination and six to 10 weeks after the second dose. The study found the levels to be negatively correlated with age in those who hadn’t been previously infected, with the highest antibody levels among those younger than 35.

This research follows a preprint study released ahead of peer review earlier this month that suggested that the Moderna vaccine’s effectiveness dropped to 76 percent and the Pfizer shot’s effectiveness fell to 42 percent in July when the delta variant had taken hold in the U.S.

That preliminary study from the Mayo Clinic emphasized that both vaccines still are highly protective against infection and serious illness. The research was also accompanied by a notice that the early findings “should not be used to guide clinical practice.”

In the U.S., more than 94 million people are fully vaccinated with the Pfizer-BioNTech shot, and more than 65 million are fully vaccinated with the Moderna vaccine. Another 14 million have received the single-dose Johnson & Johnson shot, according to data from the Centers for Disease Control and Prevention (CDC).

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PITTSBURGH - A resident of Murrysville, Pennsylvania, was sentenced in federal court following his convictions for unlawful dispensing and distributing Schedule II controlled substances and health care fraud, United States Attorney Cindy K. Chung announced today.

Senior United States District Judge Nora Barry Fischer sentenced Yee Chung Ho, age 72, a physician, to three years of probation, including 180 days of home detention. Ho also was ordered to pay restitution totaling $6,500 to Medicare, and to forfeit his Drug Enforcement Administration number, Pennsylvania state license to practice medicine, and $89,280.00 to the United States. Ho was further ordered to serve 250 hours of community service.

During the defendant’s plea hearing on November 9, 2021, Ho admitted that, while practicing as a licensed medical doctor at his family medicine practice located in Pittsburgh, Pennsylvania, he knowingly dispensed and distributed Schedule II drugs, specifically, Oxycodone, to a patient outside the usual course of professional practice and not for a legitimate medical purpose. Ho also admitted that, from April 2018 through June 2019, he committed health care fraud by causing fraudulent claims to be submitted to Medicare for payments to cover the costs of unlawfully prescribed drugs.

Assistant United States Attorneys Robert Cessar and Karen Gal-Or and Special Assistant United States Attorney Edward Song are prosecuting this case on behalf of the government.

The investigation leading to the filing of charges in this case was conducted by the Western Pennsylvania Opioid Fraud and Abuse Detection Unit (OFADU). The Western Pennsylvania OFADU, led by federal prosecutors in the U.S. Attorney’s Office, combines the expertise and resources of federal and state law enforcement to address the role played by unethical medical professionals in the opioid epidemic.

The agencies which comprise the Western Pennsylvania OFADU include: Federal Bureau of Investigation, U.S. Health and Human Services – Office of Inspector General, Drug Enforcement Administration, Internal Revenue Service-Criminal Investigations, Pennsylvania Office of Attorney General - Medicaid Fraud Control Unit, Pennsylvania Office of Attorney General – Bureau of Narcotic Investigations, United States Postal Inspection Service, U.S. Attorney’s Office – Criminal Division, Civil Division and Asset Forfeiture Unit, Department of Veterans Affairs-Office of Inspector General, Food and Drug Administration-Office of Criminal Investigations, U.S. Office of Personnel Management – Office of Inspector General and the Pennsylvania Bureau of Licensing.

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Miami, Florida – Over 50 defendants were charged in the Southern District of Florida in the last six weeks, as part of a nationwide federal law enforcement action to combat health care fraud.

The federal charges filed in South Florida cover a wide range of schemes, from novel crimes like theft of Covid-19 personal protection equipment and fraud connected to substance abuse treatment facilities (sober homes), to more familiar violations like health care fraud involving durable medical equipment suppliers, home health, pharmacies, payment of kickbacks, money laundering, and more. It is alleged that $308 million in fraudulent claims was billed by the defendants charged in the Southern District of Florida during the six-week enforcement period. Over $106 million of that billed amount was paid.  

Nationwide, 138 defendants, including 42 doctors, nurses, and other licensed medical professionals, in 31 federal districts across the United States, were charged during the enforcement period for their alleged participation in various healthcare fraud schemes that resulted in approximately $1.4 billion in alleged losses. Nationally, the charges target approximately $1.1 billion in fraud committed using telemedicine (the use of telecommunications technology to provide health care services remotely), $29 million in COVID-19 health care fraud, $133 million connected to substance abuse treatment facilities, or “sober homes,” and $160 million connected to other health care fraud and illegal opioid distribution schemes across the country.

“The results of the coordinated law enforcement effort that we announce today exemplify my Office and its law enforcement partners’ enduring commitment to combatting all forms of health care fraud-related schemes.” said Juan Antonio Gonzalez, Acting U.S. Attorney for the Southern District of Florida. “We will not relent in holding accountable those in South Florida who exploit health care programs and patient trust for personal gain, particularly during the COVID-19 global pandemic.”

“This nationwide enforcement action demonstrates that the Criminal Division is at the forefront of the fight against health care fraud and opioid abuse by prosecuting those who have exploited health care benefit programs and their patients for personal gain,” said Assistant Attorney General Kenneth A. Polite Jr. of the Justice Department’s Criminal Division. “The charges announced today send a clear deterrent message and should leave no doubt about the department’s ongoing commitment to ensuring the safety of patients and the integrity of health care benefit programs, even amid a continued pandemic.”

Today’s enforcement actions were led and coordinated by the Health Care Fraud Unit of the Criminal Division’s Fraud Section, in conjunction with its Health Care Fraud and Appalachian Regional Prescription Opioid (ARPO) Strike Force program, and its core partners, the U.S. Attorneys’ Offices, the Department of Health and Human Services Office of Inspector General (HHS-OIG), FBI, and the Drug Enforcement Administration (DEA), as part of the department’s ongoing efforts to combat the devastating effects of health care fraud and the opioid epidemic.

The Southern District of Florida, in particular, worked with the Department’s Criminal Division and the following law enforcement organizations to investigate and prosecute the cases filed during the enforcement period: FBI Miami; U.S. Department of Health and Human Services, Office of Inspector General (HHS-OIG), Miami Region; Social Security Administration, Office of Inspector General (SSA-OIG), Atlanta Field Division; Homeland Security Investigations (HSI), Miami; United States Postal Inspection Service (USPIS), Miami Region; Florida’s Office of the Attorney General, Medicaid Fraud Control Unit (MFCU); Florida State Attorney’s Office; City of Miami Beach Police Department; Palm Beach County Sober Homes Task Force; Amtrack Office of the Inspector General; and the Department of Insurance Fraud.

“South Florida is ground zero for health care fraud. As such, the FBI and its partners devote vast resources to investigate, catch and prosecute those committing this fraud,” said George L. Piro, Special Agent in Charge, FBI Miami. The victims are U.S. taxpayers, you and me. Our message to those who commit health care fraud and steal from U.S. taxpayers is clear: you will be caught, and you will be punished.”

“Healthcare fraud is hardly a victimless crime. The well-being and trust of patients and taxpayers are at risk when corrupt providers engage in schemes that drain taxpayer-funded health care programs and undermine impartial medical judgement,” said Special Agent in Charge Omar Pérez Aybar of HHS-OIG Miami. “These cases demonstrate our resolve to investigate bad actors and protect the patients served by vital federal health and human services programs.”

“Those who misuse the Social Security numbers of other individuals for personal gain are warned -- we will hold you accountable.” said Rodregas W. Owens, Special Agent-in-Charge, SSA-OIG, Atlanta Field Division. “We will continue to work aggressively to identify such fraud in an effort to protect taxpayers against fraud, waste, and abuse.”

“We as a law enforcement community will not allow individuals to defraud government health-care programs for their own personal gain,” said Anthony Salisbury, Special Agent in Charge, HSI Miami. “HSI and its partners will continue to pursue individuals and companies who are taking advantage of innocent patients seeking medical care.”

“My Medicaid Fraud Control Unit works tirelessly to stop the exploitation of the taxpayer-funded Medicaid program and protect the vulnerable Floridians who rely on its services. I’m proud of our partnership with federal authorities to hold these criminals abusing the system accountable,” said Florida Attorney General Ashley Moody.

COVID-19 Fraud Cases

Across the nation, nine defendants are charged with engaging in various health care fraud schemes designed to exploit the COVID-19 pandemic, which resulted in the submission of over $29 million in false billings.

In the Southern District of Florida, for example, a defendant is charged with stealing personal protective equipment from a hospital and reselling it at inflated prices:  

In U.S. v. Rickey Delancey, Jr., Case No. 21-20471-Cr-Moore, a 30-year-old Miami resident is charged by indictment with conspiracy to steal medical products, theft of medical products, and transportation of stolen goods. According to the indictment, Delancey worked in the supplies department of Mount Sinai Hospital. From about April to November 2020, Delancey stole N95 masks and other medical supplies from his workplace and sold them to various purchasers. Among other items, he sold $55,000 worth of stolen masks to a purchaser in California, says the indictment. As a result of the thefts, during the height of the COVID-19 pandemic, Mount Sinai did not have the supplies needed for nurses, doctors, staff, and patients, and at one point was down to only a three-day supply of N95 masks.

FBI Miami and USPIS Miami investigated this case, along with City of Miami Beach Police Department. Southern District of Florida Assistant U.S. Attorney Lindsey Lazopoulos Friedman is prosecuting it.

The law enforcement action today also includes criminal charges against five defendants across the country who allegedly engaged in the misuse of Provider Relief Fund monies. The Provider Relief Fund is part of the Coronavirus Aid, Relief, and Economic Security (CARES) Act, a federal law enacted March 2020 designed to provide needed medical care to Americans suffering from COVID-19.

The COVID-19 cases announced today build upon the success of the COVID-19 Health Care Fraud Takedown on May 26, a coordinated law enforcement action against 14 defendants in seven judicial districts for over $128 million in false billings. The law enforcement action and the cases announced today were brought in coordination with the Health Care Fraud Unit’s COVID-19 Interagency Working Group, which is chaired by the National Rapid Response Strike Force and organizes efforts to address illegal activity involving health care programs during the pandemic.

Sober Homes Cases

Today’s announcement of sober homes cases charged across the nation coincides with the one-year anniversary of the first national sober homes initiative in 2020, which included charges against more than a dozen criminal defendants in connection with more than $845 million of allegedly false and fraudulent claims for tests and treatments for vulnerable patients seeking treatment for drug and/or alcohol addiction. The over $133 million in false and fraudulent claims that are additionally alleged in cases announced today reflect the continued effort by the National Rapid Response Strike Force and the Health Care Fraud Unit’s Los Angeles Strike Force, with the participation of the U.S. Attorney’s Offices for the Central District of California and the Southern District of Florida, to prosecute those who participated in illegal kickback and bribery schemes involving the referral of patients to substance abuse treatment facilities; those patients could be subjected to medically unnecessary drug testing – often billing thousands of dollars for a single test – and therapy sessions that frequently were not provided, and which resulted in millions of dollars of false and fraudulent claims being submitted to private insurers.

In the Southern District of Florida, two defendants are charged with sober homes fraud:

In United States v. Mimi Bieda and Levi Bieda a/k/a Larry, Case No. 21-80112-CR-Rosenberg, Mimi Bieda, 62, and Levi Bieda, 36, of West Palm Beach, Florida, are charged by information with conspiracy to commit $128 million of health care fraud. According to the information, the Biedas owned and operated Academy Health Solutions, LLC (“Academy”), a substance abuse treatment center in Palm Beach County, Florida, as well as a sober home and detox facilities. They also had ownership interest in several drug testing laboratories. It is alleged that the Biedas hired a medical director for Academy, Dr. Michael Ligotti, who signed standing orders for medically unnecessary and expensive drug testing in exchange for patient referrals. Dr. Ligotti then billed the patients’ insurance plans for duplicative, excessive, non-rendered, and/or medically unnecessary treatment and testing. The Biedas used the standing orders signed by Dr. Ligotti, and by a subsequent medical director at Academy, to authorize medically unnecessary drug testing at laboratories in which they had an ownership interest, allowing them to receive percentages of all claim reimbursements for those tests, says the information. It is alleged that the Biedas also paid kickbacks and bribes, in the form of free or reduced rent, access to controlled substances provided by Academy’s medical directors, and other benefits, to individuals who agreed to live at their sober home, attend treatment at Academy, and submit to drug testing, so that the Biedas could bill these services to the residents’ insurance plans.

FBI Miami investigated this case, along with Palm Beach County Sober Homes Task Force, Florida State Attorney’s Office, Amtrack Office of the Inspector General, and Department of Insurance Fraud. Southern District of Florida Assistant United States Attorneys Alexandra Chase and Danielle Croke, as well as National Rapid Response Strike Force Senior Litigation Counsel James V. Hayes and Trial Attorney Ligia Markman are prosecuting it.

Cases Involving Traditional Healthcare Fraud Schemes and the Illegal Prescription and/or Distribution of Opioids

The cases announced today that fall into more traditional categories of health care fraud include charges filed across the nation against over 60 defendants who allegedly participated in schemes to submit more than $145 million in false and fraudulent claims to Medicare, Medicaid, TRICARE, and private insurance companies for treatments that were medically unnecessary and often never provided. Cases filed across the nation involving the illegal prescription and/or distribution of opioids involve 19 defendants, including several charges against medical professionals and others who prescribed over 12 million doses of opioids and other prescription narcotics, while submitting over $14 million in false billings.

In the Southern District of Florida, defendants are charged in cases involving a wide range of traditional health care fraud schemes. Some of the cases charged in the Southern District of Florida during the six-week enforcement period include the following:

In United States v. Edward Pizzi, Case No. 21-20467-CR-Altman, a 40-year-old from Miami, Florida is charged by information with conspiracy to pay health care kickbacks. According to the information, Pizzi owned and operated Miami-based Rios Medical Center and Union Medical Clinic. Pizzi directed his employees to pay kickbacks to recruit Medicare beneficiaries and Medicaid recipients to the clinics. The clinics used the identification numbers of these beneficiaries and recipients to submit claims to Medicare Part C and Medicaid for, among other things, purported mental health therapy services. Most of the recruited beneficiaries neither needed nor qualified for such services.

FBI Miami, HHS-OIG Miami, and MFCU investigated this case. Southern District of Florida Assistant U.S. Attorney Michael Homer is prosecuting it.

In United States v. Mayara Gonzalez Chaviano, Case No. 21-20468-CR-King, a 28-year-old Miami, Florida resident is charged by information with conspiracy to pay health care kickbacks. According to the information, Chaviano was the office manager of Rios Medical Center and Union Medical Clinic, in Miami, Florida. Chaviano managed the clinics’ scheme to pay kickbacks to recruit Medicare beneficiaries and Medicaid recipients to the clinics. The clinics used the identification numbers of these beneficiaries and recipients to submit claims to Medicare Part C and Medicaid for, among other things, purported mental health therapy services. Most of the recruited beneficiaries neither needed nor qualified for such services.

FBI Miami, HHS-OIG Miami, and MFCU investigated this case. Southern District of Florida Assistant U.S. Attorney Michael Homer is prosecuting it.

In United States v. Liliana Liseth Duarte, Case No. 21-20469-CR-Bloom, a 47-year-old resident of Miami, Florida, is charged by information with conspiracy to pay health care kickbacks. According to the information, Duarte was an employee of Rios Medical Center and Union Medical Clinic, in Miami, Florida. Duarte paid kickbacks to individuals to recruit Medicare beneficiaries and Medicaid recipients to the clinics. The clinics used the identification numbers of these beneficiaries and recipients to submit claims to Medicare Part C and Medicaid for, among other things, purported mental health therapy services. Most of the recruited beneficiaries neither needed nor qualified for such services.

FBI Miami, HHS-OIG Miami, MFCU investigated this case. Southern District of Florida Assistant U.S. Attorney Michael Homer is prosecuting it.

In United States v. Jason Kashou, Case No. 21-60245-CR-Dimitrouleas, the 35-year-old owner of 1st Choice is charged by information with conspiracy to solicit and receive illegal kickbacks from pharmacies. Kashou bought Medicare and Medicaid beneficiary information from a call center in India. Kashou then agreed to provide the beneficiary information to pharmacies so that the pharmacies could fill prescriptions for expensive diabetic supplies and topical pain creams. In exchange, the pharmacies agreed to pay Kashou a percentage of the profits from the amount Medicare and Medicaid paid on a per patient basis.

On September 14, Kashou pled guilty to the charge. His sentencing hearing is set for November 23, at 1:15 p.m., before U.S. District Judge William P. Dimitrouleas.

HSI Miami, HHS-OIG Miami and MFCU investigated this case. Southern District of Florida Assistant U.S. Attorneys Stephanie Hauser and Michael Gilfarb are prosecuting it.

In United States v. Greisy Rosario Varona Docasal, Case No. 21-20439-CR-Cooke, a 52-year-old Miami, Florida resident is charged by indictment with conspiracy to receive health care kickbacks, and substantive counts of receiving kickbacks in connection with a federal health care program. According t0 the indictment, Varona Docasal, as office manager of a doctor’s office, was involved in a scheme to illegally recruit Medicare beneficiaries and refer them to home health agencies in exchange for receiving illegal kickbacks from the owners and operators of the home health agencies who in turn billed Medicare for home health services for the recruited Medicare beneficiaries.

HHS-OIG Miami investigated this case. Southern District of Florida Assistant U.S. Attorney Aimee C. Jimenez is prosecuting it.

In United States v. Mayra De La Paz, Case No. 21-20474-CR-Bloom, a 69-year-old resident of Hialeah, Florida is charged by information with conspiracy to solicit and receive kickbacks in connection with a federal health care program. According to the information, De La Paz participated in a conspiracy to solicit and receive kickback payments for the referral of Medicare beneficiaries to a home health agency.

HHS-OIG Miami and FBI Miami investigated this case. Southern District of Florida Assistant U.S. Attorney Timothy J. Abraham is prosecuting it.

In U.S. v. Michael Marcelus Mogollon, Case No. 21-20432-CR-Moore, a 33-year-old from Miami, Florida is charged by information with conspiracy to commit health care and wire fraud. According to the information, Mogollon paid kickbacks to beneficiaries with Blue Cross Blue Shield health insurance in exchange for the patients allowing Miami clinics Quality Professional, Zion Medical, and Renewal to bill the insurance plans for medical benefits, items, and services, that were not medically necessary, not eligible for reimbursement, and not received by the beneficiaries. As a result of Mogollon’s participation in the conspiracy, the clinics billed Blue Cross Blue Shield approximately $678,800, and Blue Cross Blue Shield paid approximately $220,000 based on the false claims, says the information.

FBI Miami investigated this case. Southern District of Florida Assistant U.S. Attorney Lindsey Lazopoulos Friedman is prosecuting it.  

In U.S. v. Jorge Luis Taboada, Case No. 21-20443-CR-Williams, a 52-year-old resident of Miami, Florida is charged by information with conspiracy to commit health care and wire fraud. According to the information, Taboada paid kickbacks to beneficiaries with Blue Cross Blue Shield and Aetna health insurance in exchange for the patients allowing United Medical of South Florida, d/b/a Sleep Study of South Florida, Inc. to bill the insurance plans for medical benefits, items, and services, that were not medically necessary, not eligible for reimbursement, and not received by the beneficiaries. As a result of Taboada’s participation in the conspiracy, the clinics billed Blue Cross Blue Shield and Aetna between $1,500,000 and $3,500,000, says the information.

FBI Miami investigated this case. Southern District of Florida Assistant U.S. Attorney Lindsey Lazopoulos Friedman is prosecuting it.  

In United States of America vs. Patricia M. Cleary, a/k/a Patricia M. Cleary Syling, a/k/a Patricia M. Syling, a/k/a Patricia A. Cleary, Case No. 21-60262-CR-Singhal, a 51-year-old from Odessa, Florida is charged by indictment with one count of falsely representing a social security number and one count of aggravated identity theft.

According to the indictment, Cleary knowingly gave a false social security number to a Medicaid Managed Care Organization while applying for a job with the company. The social security number did not belong to Cleary. Instead, it belonged to a victim living in a different state. Cleary did this to hide her real identity from the company, says the indictment.

HHS-OIG Miami, State of Florida Medicaid Fraud Control Unit, SSA-OIG Miami, and FBI Miami investigated this case. Southern District of Florida Special Assistant U.S. Attorney Marc Canzio is prosecuting it.

In United States v. Julio Cesar Betancourt, Case No. 21-20425-CR-Moore, a 31-year-old resident of Hialeah Gardens, Florida is charged by information with conspiracy to commit money laundering. According to the information, Betancourt, as owner of owner of JD Solution USA, Inc., conspired to launder $363,139 in health care fraud proceeds between July 2019 and October 2019. These proceeds were related to a durable medical equipment company located in Miami that was committing health care fraud, says the information.

HHS-OIG Miami and FBI Miami investigated this case. Southern District of Florida Assistant U.S. Attorney Timothy J. Abraham is prosecuting it.

In United States v. Jorge Luis Lopez Pena, Case No. 21-CR-20466-Gayles, a 36-year-old from Miami, Florida is charged by information with conspiracy to commit money laundering. According to the information, Lopez Pena, as owner of Lopez Distributors, Inc., conspired to launder $185,671 in health care fraud proceeds between August 2019 and December 2019. These health care fraud proceeds were related to a durable medical equipment company located in Miami that was committing health care fraud, says the information.

HHS-OIG Miami and FBI Miami investigated this case. Southern District of Florida Assistant U.S. Attorney Timothy J. Abraham is prosecuting it.

In U.S. v. Angel Pimentel, Case No. 21-20420-CR-King, a 72-year-old from Miami, Florida, is charged by indictment with conspiracy to commit health care fraud and substantive counts of health care fraud. According to the indictment, Pimentel owned Maggie Pharmacy Discount, Inc. From about March 2015 to August 2019, Pimentel submitted $988,983 in claims to Medicare, which falsely and fraudulently represented that various health care benefits, primarily prescription drugs, were medically necessary, prescribed by a doctor, and had been provided by Maggie Pharmacy Discount, Inc. to Medicare beneficiaries. As a result of the false claims, Medicare prescription drug plan sponsors, through their pharmacy benefit managers, made payments funded by the Medicare Part D Program to the corporate bank accounts of Maggie Pharmacy Discount, Inc. of at least $988,983, says the indictment.

HHS-OIG Miami and FBI Miami investigated this case. Southern District of Florida Assistant U.S. Attorney Christopher J. Clark is prosecuting it.

Prior to the charges announced as part of today’s nationwide enforcement action and since its inception in March 2007, the Health Care Fraud Strike Force, which maintains 15 strike forces operating in 24 districts, has charged more than 4,600 defendants who have collectively billed the Medicare program for approximately $23 billion. In addition to the criminal actions announced today, CMS, working in conjunction with HHS-OIG, announced 28 administrative actions to decrease the presence of fraudulent providers.

Telemedicine Fraud Cases

More than 43 criminal defendants in 11 judicial districts nationwide are charged in cases involving telemedicine: the use of telecommunications technology to provide health care services remotely. It is alleged that these telemedicine defendants filed over $1.1 billion in fraudulent claims.

The continued focus on prosecuting health care fraud schemes involving telemedicine reflects the success of the nationwide coordinating role of the Fraud Section’s National Rapid Response Strike Force, the creation of which was announced at the 2020 National Health Care Fraud and Opioid Takedown. The National Rapid Response Strike Force helped coordinate the prosecution of the telemedicine initiative, Sober Homes initiative, and COVID-19 cases that were announced today. The focus on telemedicine fraud also builds on the telemedicine component of last year’s national takedown and the impact of the 2019 “Operation Brace Yourself” Telemedicine and Durable Medical Equipment Takedown, which resulted in an estimated cost avoidance of more than $1.9 billion in the amount paid by Medicare for orthotic braces in the 20 months following that takedown.

Health Care Fraud Prosecutions in the Southern District of Florida for

Fiscal Year 2020-2021

The Southern District of Florida is a national leader in health care fraud prosecutions. So far, during the 2020-2021 Fiscal Year (from October 1, 2020 through today), a total of 196 defendants have been charged in the Southern District of Florida with health care fraud-related offenses. It is alleged that approximately $2.2 billion was billed by these defendants and that approximately $488 million was paid.

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Each Defendant Excluded from Federal Healthcare Programs for Six Years

Neurosurgeon Wilson Asfora, M.D. of Sioux Falls, South Dakota, and two medical device distributorships that he owns, Medical Designs LLC and Sicage LLC, have agreed to pay $4.4 million to resolve False Claims Act allegations relating to illegal payments to Asfora to induce the use of certain medical devices, in violation of the Anti-Kickback Statute, as well as claims for medically unnecessary surgeries.

Medical Designs and Sicage agreed to pay an additional $100,000 in penalties to settle allegations that they violated the Open Payments Program by failing to report to the Centers for Medicare & Medicaid Services (CMS) Asfora’s ownership interests and payments made to Asfora.

Under the terms of the settlement agreement, Asfora, Medical Designs, and Sicage each will be excluded from participation in federal healthcare programs for a period of six years.

“Physicians who accept kickbacks and perform unnecessary surgeries put their patients at risk and increase healthcare costs for everyone,” said Acting Assistant Attorney General Brian M. Boynton of the Department of Justice’s Civil Division. “We will continue to hold physicians and medical device companies accountable for unlawful financial arrangements that undermine the integrity of federal healthcare programs.”

The settlement announced today resolves allegations that over the course of nearly a decade, Asfora, Medical Designs, and Sicage knowingly and willfully engaged in three kickback schemes to allow Asfora to profit from his use of over a dozen devices in his medical procedures. First, the United States alleged that Medical Designs and Sicage paid Asfora profit distributions in exchange for Asfora using Medical Designs’ and Sicage’s devices in his spine surgeries. Second, the United States alleged that Medical Designs acted as a distributor, reselling other manufacturers’ spinal devices and splitting the profits with Asfora when he used those devices in surgeries. Third, the United States alleged that Asfora solicited and received kickbacks from medical device manufacturer Medtronic USA Inc. in exchange for using its SynchroMed II infusion pumps, which are implantable devices used to deliver medication to patients. At Asfora’s request, Medtronic allegedly paid the kickbacks to Asfora through a restaurant he owned with his wife, called Carnaval Brazilian Grill, in the form of lavish meals and alcohol for Asfora and his friends, colleagues, and business partners.

In addition, the settlement resolves allegations that Asfora knowingly submitted false claims to federal healthcare programs for medically unnecessary procedures using the devices in which he had a financial interest. Despite receiving numerous warnings that he was performing medically unnecessary procedures – including warnings from his own physician colleagues – Asfora allegedly continued to perform such procedures while personally profiting from his use of devices sold by Medical Designs, Sicage, and Medtronic.

“Fraud in the healthcare arena is taken very seriously by the Department of Justice,” said Acting U.S. Attorney Dennis R. Holmes for the District of South Dakota. “South Dakota is fortunate to have many honest and dedicated healthcare providers who strive daily to provide high quality services. Dr. Asfora and his companies violated the trust that so many others have worked hard to earn.”

“Kickback dollars can corrupt the high quality medical care patients deserve and taxpayers fund,” said Special Agent in Charge Curt L. Muller of the U.S. Department of Health and Human Services Office of Inspector General (HHS-OIG). “We have excluded Dr. Asfora and his two medical distributorships from receiving Medicare, Medicaid, and other federal health program dollars.”

This settlement also resolves Medical Designs’ and Sicage’s liability under CMS’ Open Payments Program, which was established by the Affordable Care Act and requires medical device companies to disclose to CMS physician ownership interests and certain payments or other transfers of value to a physician.

The civil settlement includes the resolution of claims that Drs. Carl Dustin Bechtold and Bryan Wellman brought under the qui tam or whistleblower provisions of the False Claims Act against Asfora and Medical Designs. Under the qui tam provisions of the False Claims Act, a private party can file an action on behalf of the United States and receive a portion of any settlement. The qui tam case is captioned United States ex rel. Bechtold, et al. v. Asfora, et al., No. 4:16-cv-04115-LLP (D.S.D.). The whistleblowers will receive $880,000 of the settlement proceeds.

This settlement was the result of a coordinated effort between the Civil Division's Commercial Litigation Branch, Fraud Section, and the U.S. Attorney’s Office for the District of South Dakota, with assistance from HHS-OIG. As a result of its efforts, the United States has recovered a total of more than $33 million relating to conduct involving Asfora, including a False Claims Act settlement with Sanford Health entities for $20.25 million in October 2019 and a False Claims Act and Open Payments settlement with Medtronic for $9.21 million in October 2020. This matter and the related matters were investigated by Trial Attorneys Christopher Terranova and Harin C. Song and Assistant U.S. Attorneys Meghan K. Roche and Ellie J. Bailey.  

The claims resolved by the settlement are allegations only, and there has been no determination of liability.

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A federal jury convicted a New Jersey rheumatologist today for defrauding Medicare and other health insurance programs by billing for services that patients never received.

According to court documents and evidence presented at trial, Alice Chu, 64, of Fort Lee, owned and operated a rheumatology practice in Clifton. From 2010 through 2019, Chu billed Medicare and other health insurance programs for expensive infusion medication that her practice never purchased. Chu also fraudulently billed millions of dollars for allergy services that patients never needed or received.

Chu was convicted of one count of conspiracy to commit health care fraud and five counts of health care fraud. She is scheduled to be sentenced on July 14 and faces a maximum penalty of 10 years in prison for each count. A federal district court judge will determine any sentence after considering the U.S. Sentencing Guidelines and other statutory factors.

Assistant Attorney General Kenneth A. Polite Jr. of the Justice Department’s Criminal Division; Assistant Director Luis Quesada of the FBI’s Criminal Investigative Division; Special Agent in Charge George M. Crouch Jr. of the FBI’s Newark Field Office; Special Agent in Charge Scott J. Lampert of the Department of Health and Human Service Office of the Inspector General (HHS-OIG); and Special Agent in Charge Patrick J. Hegarty of the Department of Defense Office of Inspector General, Defense Criminal Investigative Service (DOD-OIG) made the announcement.

The FBI, HHS-OIG and DOD-OIG investigated the case.

Acting Assistant Chief Rebecca Yuan and Trial Attorney Nicholas Peone of the Justice Department’s Fraud Section are prosecuting the case.

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WHEELING, WEST VIRGINIA – A new initiative to combat health care fraud in West Virginia was launched today in Wheeling, according to United States Attorney William Ihlenfeld.

State and federal agencies gathered at the U.S. Attorney’s office this morning for the first meeting of the Mountaineer Health Care Fraud Strike Force, a unit that will take a data-driven approach to uncovering waste and abuse. Representatives from seven different agencies discussed fraudulent billing patterns and new targets were identified as a result.

In addition to its analytical work, the Strike Force will engage with providers and insurers so that there is a better understanding on how to recognize and report health care fraud.

“The time I spent in the private sector opened my eyes to the scope of the health care fraud that is occurring in West Virginia,” said Ihlenfeld. “It made me realize that more can and should be done by law enforcement, which is why this new group has been formed.”

Ihlenfeld stressed the importance of whistleblowers and the impact that they can have upon uncovering fraud.

“Oftentimes the first person to witness fraud is an employee of a hospital or a doctor’s office,” Ihlenfeld remarked. “Those who blow the whistle and expose conduct that the government was not able to detect on its own are awarded a portion of the amount recovered, and those awards can be substantial."

Last year, a whistleblower was awarded $10 million in the matter of U.S. ex rel. Longo v. Wheeling Hospital, Inc. Read more here: https://www.justice.gov/usao-ndwv/pr/west-virginia-hospital-agrees-pay-50-million-settle-allegations-concerning-improper

A new hotline, email address and mailing address have been established to allow for the reporting of potential fraud. Anyone with information may call (304) 234-7711, send an email to This email address is being protected from spambots. You need JavaScript enabled to view it., or mail correspondence to the U.S. Attorney’s Office, Attn: Mountaineer HCF Strike Force, P.O. Box 591, Wheeling, WV 26003.

“Fraud and abuse take critical resources out of our health care system and contribute to rising costs for everyone,” said FBI Special Agent in Charge Mike Nordwall. “It costs U.S. taxpayers tens of billions of dollars annually. The FBI, along with state, local and federal partners, are working side by side to help stop West Virginians from having to absorb the costs associated with health care fraud. I hope the community will use this tip line to aid us in our efforts to hold those who commit fraud accountable.”

“The newly formed team will combine the talents, dedication, and resources of federal law enforcement and the State of West Virginia to fight health care fraud, waste, and abuse,” said Maureen R. Dixon, Special Agent in Charge for the Department of Health and Human Services, Office of Inspector General (HHS-OIG). “We look forward to working with our law enforcement partners in this collaborative initiative to prevent and detect health care fraud, hold wrongdoers accountable, and ensure appropriate use of taxpayer funds.”

Members of the Mountaineer Health Care Fraud Strike Force include agents, officers and prosecutors from the Federal Bureau of Investigation (FBI), the U.S. Department of Health and Human Resources (HHS), the Drug Enforcement Administration (DEA), the U.S. Department of Defense, the West Virginia Medicaid Fraud Control Unit, the West Virginia Offices of Insurance Commission, and the United States Attorney’s Office.

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RALEIGH, N.C. – A North Carolina corporation was sentenced today to 5 years’ probation and ordered to pay a $2,000,000 fine in addition to paying $10,069,361.35 in restitution to the North Carolina Medicaid Program on a charge of Healthcare Fraud, in violation of Title 18, United States Code, Section 1347. The company and its owner have also agreed to pay millions to the United States and State of North Carolina to resolve related civil claims under the federal and state False Claims Acts. In that same civil action, the Governments have obtained a multi-million-dollar judgment against one of the company’s employees.

According to court documents, A Perfect Fit for You, Inc., was a durable medical equipment provider located in Morehead City, North Carolina, and owned by Margaret A. Gibson.   Durable medical equipment includes items such as powered wheelchairs, orthotic braces, diabetic shoes, powered air flotation beds, osteogenesis stimulators, pneumatic compressors, etc. Between March 2015 and November 2016, one or more employees of A Perfect Fit for You submitted fraudulent billings claims to Medicaid for providing durable medical equipment to Medicaid recipients. These fraudulent claims contained the personal identifying information of Medicaid recipients who had never ordered nor received any durable medical equipment from A Perfect Fit for You.   In fact, some of the patients had been deceased years before the false claims were even submitted. This scheme resulted in an estimated loss to Medicaid of approximately $10,069,361.35.

After appointment of a receiver, A Perfect Fit for You, Inc. self-reported suspected fraudulent activity to the North Carolina Medicaid Investigations Division. Thereafter, the company cooperated throughout the investigation.

On December 13, 2017, and based on the conduct described above, the United States and State of North Carolina filed a civil complaint under the federal and state False Claims Acts against A Perfect Fit for You, Inc. and Gibson, as well as one of the company’s employees, Shelley P. Bandy. The federal and North Carolina False Claims Acts mandate that the Governments recover triple the money falsely obtained, plus substantial civil penalties for each false claim submitted. To resolve those claims, the company has agreed to pay $20,138,722.70, while Gibson has agreed to pay $4,000,000. As for Bandy, the United States and State of North Carolina have obtained a $34,708,945.42 default judgment against her in the civil action. It should be noted that the civil claims against A Perfect Fit for You, Inc. and Gibson are allegations only and were resolved by settlement. There has been no judicial determination or admission of liability as to them in the civil case.

On December 29, 2020, Bandy pled guilty to making false statements relating to health care matters in violation of Title 18, United States Code, Section 1035. Bandy admitted to submitting fraudulent claims to Medicaid on behalf of A Perfect Fit for You, Inc.   Bandy is scheduled to be sentenced later in March, 2021.

G. Norman Acker, III, Acting United States Attorney for the Eastern District of North Carolina made the announcement after sentencing by U.S. District Judge James C. Dever III. The investigation of this case was conducted by the North Carolina Department of Justice’s Medicaid Investigations Division (MID) and the United States Department of Health and Human Services Office of the Inspector General.   Assistant United States Attorney William M. Gilmore is the prosecutor on the criminal case, while Assistant United States Attorney C. Michael Anderson represented the United States in the civil case. Special Deputy Attorneys General F. Edward Kirby, Jr. and Michael M. Berger, who also serve as a Special Assistant United States Attorneys, represented the United States and the State of North Carolina in the civil case.

The MID investigates and prosecutes health care providers that defraud the Medicaid program, patient abuse of Medicaid recipients, patient abuse of any patient in facilities that receive Medicaid funding, and misappropriation of any patients’ private funds in nursing homes that receive Medicaid funding. To report Medicaid fraud or patient abuse in North Carolina, call the MID at 919-881-2320.

The MID receives 75 percent of its funding from the U.S. Department of Health and Human Services under a grant award totaling $6,160,252 for Federal fiscal year (FY) 2020. The remaining 25 percent, totaling $2,053,414 for FY 2020, is funded by the State of North Carolina.

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The CEO of a local hospice agency has pleaded guilty to defrauding Medicare and Medicaid, announced Acting U.S. Attorney for the Northern District of Texas Prerak Shah.

Bradley J. Harris, the 39-year-old former head of Novus and Optimum Health Services, pleaded guilty on Friday to conspiracy to commit healthcare fraud and healthcare fraud.

“Mr. Harris scammed federal healthcare programs out of millions of dollars, and worse yet, denied vulnerable patients the medical oversight they deserved, writing pain prescriptions without physician input and allowing terminally ill patients to go unexamined,” said Acting U.S. Attorney Prerak Shah. “The Justice Department cannot allow unscrupulous business people to interfere with the practice of medicine. We are determined to root out healthcare fraud.”

“In addition to causing fraudulent billing for tens of millions of dollars, Mr. Harris preyed upon patients and families that did not have a true understanding of Novus and hospice services. The core of the company was rooted in deception, and the lack of physician oversight allowed Mr. Harris to make medical decisions for his own financial benefit,” said FBI Dallas Special Agent in Charge Matthew DeSarno. “We will continue to work tirelessly with our state and federal partners to hold those who commit health care fraud accountable and seek justice for patients that are harmed in furtherance of fraud schemes.”

According to his plea papers, Mr. Harris admitted that from 2012 to 2016, he billed Medicare and Medicaid for hospice services that were not provided, that were not directed by a medical professional, or that were provided to patients who were not actually eligible for hospice care. He further admitted that he used blank, pre-signed controlled substance prescriptions to doll out potent drugs without physician input.

Mr. Harris admitted that two of his coconspirators, Dr. Mark Gibbs and Dr. Laila Hirjee, frequently certified that that his hospice patients faced terminal illnesses without actually examining with the patients in person, as required by Medicare. (A “terminal” patient is one with a life expectancy of six months or less, according to the Department of Health & Human Services.) The doctors were paid around $150 for each false order they signed.

Mr. Harris also admitted that Dr. Gibbs, Dr. Hirjee, and another physician, Dr. Charles Leach, left him blank controlled substance prescriptions, sometimes a whole pad at a time. This allowed Mr. Harris, an accountant by trade, to “prescribe” schedule II controlled substances to hospice beneficiaries without the guidance of a medical professional.

In plea papers, Mr. Harris admitted that in summer 2014, he realized he could avoid exceeding Medicare’s aggregate hospice cap by enrolling an influx of first-time hospice patients. So, he negotiated an agreement with a company called Express Medical that allowed him to access potential patient’s confidential medical information in return for using Express Medical for laboratory services and home health visits. His wife and other Novus staff then called on individuals that had at some point been patients of Express Medical to recruit them for Novus hospice services, regardless of whether they were eligible to receive benefits.

When the Center for Medicare & Medicaid Services suspended Novus based upon credible allegations of fraud, Mr. Harris and simply transferred patients from Novus to a new company, “Company A.” Dr. Gibbs became a medical director for the “new” hospice company, which used Novus staff and transferred hospice reimbursements back to Novus, Mr. Harris admitted.

The defendant now faces up to 14 years in federal prison. His sentencing hearing has been set for Aug. 3 before Chief U.S. District Judge Barbara M.G. Lynn.

Ten of Mr. Harris’ codefendants, including Dr. Leach, have already pleaded guilty. Four more, including Dr. Gibbs and Dr. Hirjee, are slated for trial on April 5.

The Federal Bureau of Investigation’s Dallas Field Office, the U.S. Department of Health & Human Services Office of Inspector General (HHS-OIG), and the Texas Attorney General’s Medicaid Fraud Control Unit conducted the investigation. Assistant U.S. Attorneys Donna Strittmatter Max, Marty Basu, and Chad Meacham are prosecuting the case.

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COLUMBUS, Ohio – A local home healthcare provider has agreed to pay half a million dollars to the government and close its operations as part of a False Claims Act settlement.

According to court documents, Academy Health Care Services is a home healthcare agency based in Dayton providing service to patients in Ohio, many of whom are disabled and living in group homes.

Academy’s owners include Jagdish, Nita and Vijay Patel, all of Ohio.

The settlement unsealed today details that the healthcare provider’s billing practices routinely caused Ohio Medicaid to pay at a higher level of reimbursement than warranted by the services provided as well as the setting in which the services were provided.

From 2014 until 2017, Academy billed for individual healthcare services when any services it actually provided were in group settings. Further, Academy nurses did not spend the time required with patients to receive reimbursement for individual services.

The healthcare provider will pay $500,000 in total, of which $250,000 is restitution.

As part of the settlement, Academy agrees to cease operations no later than June 30, 2022, and agrees that after Dec. 31, 2021, it will no longer provide services to beneficiaries of federal healthcare programs, including the Ohio Medicaid program, and will not submit claims for any services provided to beneficiaries of federal healthcare programs.

Kenneth L. Parker, United States Attorney for the Southern District of Ohio, announced the settlement and commended the work of the U.S. Department of Health and Human Services Office of Inspector General, Ohio Attorney General Dave Yost’s Medicaid Fraud Control Unit and Ohio Department of Medicaid. Deputy Civil Chief Andrew M. Malek and Assistant United States Attorney Stephanie Rawlings are representing the United States in this case.

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Audrey Strauss, the United States Attorney for the Southern District of New York, announced that AMEET GOYAL, an ophthalmologist in Rye, New York, pled guilty yesterday to perpetrating a seven-year healthcare fraud scheme by falsely billing for millions of dollars of procedures he did not perform, and also to fraudulently obtaining two Government-guaranteed loans intended to help small businesses during the COVID-19 pandemic while facing charges on pretrial release for the healthcare fraud scheme. GOYAL pled guilty before U.S. District Judge Cathy Seibel to all charges in a six-count superseding Indictment.

U.S. Attorney Audrey Strauss said: “Dr. Ameet Goyal was an experienced eye doctor who became blinded by greed and routinely defrauded patients who trusted him to heal their eyes. He grossly overbilled minor ophthalmological procedures, billed for tests and procedures that were never performed, falsified medical records, attempted to corrupt others in his practice to abet the scheme, and sent patients who refused to pay his fraudulent charges to collections. Already facing charges for defrauding patients and insurers of millions of dollars, Goyal committed a new fraud in applying for Paycheck Protection Program loans on behalf of two separate businesses and lying on the applications. Goyal looted over $630,000 in federal funds earmarked for legitimate small businesses affected by the COVID-19 pandemic. Goyal has now admitted to both fraudulent schemes, agreed to forfeit $3.6 million, and faces the possibility of a significant term of incarceration.”

According to the allegations contained in the Indictment, court filings, and statements made during court proceedings:

At all relevant times, GOYAL owned and operated the ophthalmology practice Ameet Goyal M.D. P.C., doing business as Rye Eye Associates, with offices in Rye, Mt. Kisco, and Wappingers Falls, New York, and Greenwich, Connecticut (the “Practice”). Between 2010 and 2017, GOYAL engaged in widespread healthcare fraud by consistently “upcoding” simpler, lower-paying surgical procedures and examinations as complex, higher-paying major operations in fraudulent billings submitted to Medicare, private insurance companies, and patients. As a result, GOYAL fraudulently obtained at least $3.6 million in payments for procedures he did not perform. As part of the scheme, GOYAL routinely falsified patient medical records, authoring fictitious templated operative reports that matched the complex operation he billed rather than the different minor procedure he actually performed. GOYAL also pressured other employees in the Practice to engage in the scheme, and threatened the livelihood of employees who refused to comply. GOYAL caused patients to pay thousands of dollars out of pocket for fraudulently billed charges, and initiated debt collection proceedings against patients who did not pay the full amounts of those false charges.

For example, GOYAL and others at the Practice routinely treated patients for an excision of a chalazion, a small bump on an eyelid, typically removed in less than 15 minutes. An excision of chalazion, when billed truthfully under its associated code, paid the Practice approximately $200 on average from patients and insurance programs. However, GOYAL systematically billed an excision of chalazion and other similar superficial eyelid procedures as if he had performed an orbitotomy together with a conjunctivoplasty, which are complex surgeries into the orbit of the eye, often to remove an orbital tumor together with grafting to close the resulting wound, that typically take an hour or more to perform. These substantial surgeries, as billed, paid the Practice approximately $1,400 on average from a combination of insurance and patient out-of-pocket payments. GOYAL also upcoded certain superficial procedures as an excision and repair of eyelid, a type of higher-paying eyelid surgery involving reconstruction or removal of certain lesions other than chalazions. During the relevant time period, GOYAL billed less than 40 chalazions under the billing code designated for excision of chalazion, while billing over 1,400 orbitotomies, over 700 bundled conjunctivoplasties, and over 1,600 excision and repair of eyelid surgeries, all of which he claimed to have personally performed. The scheme involved numerous other CPT codes for procedures and examinations not performed or upcoded, resulting in at least $3.6 million of ill-gotten gains for GOYAL.

On November 21, 2019, an indictment (the “Indictment”) was returned in the action United States of America v. Ameet Goyal, 19 Cr. 844 (CS) (S.D.N.Y.), charging GOYAL with healthcare fraud, wire fraud, and making false statements relating to healthcare matters. On November 22, 2019, GOYAL was arraigned on the Indictment and placed on pretrial release pursuant to an order that notified GOYAL of the potential effect of committing a criminal offense while on pretrial release.

The Coronavirus Aid, Relief, and Economic Security (“CARES”) Act is a federal law enacted on March 29, 2020, designed to provide emergency financial assistance to the millions of Americans who are suffering the economic effects caused by the COVID-19 pandemic. One source of relief provided by the CARES Act was the authorization of hundreds of billions of dollars in forgivable loans to small businesses for job retention and certain other expenses through the Small Business Administration’s (“SBA”) Paycheck Protection Program (“PPP”). Applicants with pending criminal charges are ineligible for PPP loans. The PPP also limits each eligible borrower to one loan, and a maximum loan amount calculated based on a business’s average monthly payroll expenses.

In or about April 2020, GOYAL applied to the SBA and Bank-1, a federally insured institution, for over $630,000 in Government-guaranteed loans through the SBA’s PPP Program. Specifically, on or about April 21, 2020, GOYAL applied for a loan in the amount of $358,700 for the business “Ameet Goyal,” with his own social security number and email address. On or about April 29, 2020, GOYAL applied for a second loan in the amount of $278,500, with a business name “Rye eye associates,” using the Employer Identification Number for Ameet Goyal M.D. P.C and a different email address controlled by GOYAL. To substantiate each loan, however, GOYAL submitted the exact same underlying payroll expense report, showing the same employees and payroll costs.

On both applications, GOYAL falsely answered that he was not facing any pending criminal charges, and electronically placed his initials “AG” directly under his “No” response. GOYAL also falsely certified, among other things, that his business would not receive another PPP loan until the end of the year. After obtaining approval from Bank-1 and the SBA through his fraudulent misrepresentations, GOYAL executed loan notes for two loans. On May 4, 2020, GOYAL received the first loan of $358,700, and on May 11, 2021, GOYAL received the second loan of $278,500. GOYAL used the business checking account into which these funds were deposited to pay business and personal expenses, including by making a $1,800 payment to a country club in Westchester, New York, within days of receiving the first loan.                    

*                     *                     *

GOYAL, 58, of Rye, New York, pled guilty to all six counts in the Superseding Indictment. The first count charged healthcare fraud, which carries a maximum sentence of 10 years in prison; the second count charged wire fraud, which carries a maximum sentence of 20 years in prison; and the third count charged making false statements relating to health care matters, which carries a maximum sentence of five years in prison. Counts four, five, and six charged that while on pretrial release, the defendant committed the following offenses, respectively: bank fraud, which carries a maximum sentence of 30 years in prison; making false statements on a loan application, which carries a maximum sentence of 30 years in prison; and making false statements in a matter within the jurisdiction of the executive branch of the Government of the United States, which carries a maximum sentence of five years in prison. Additionally, a conviction under counts four, five, and six, if committed while on pretrial release, provides for an additional maximum sentence of 10 years in prison consecutive to any other sentence of imprisonment.

The maximum potential sentences are prescribed by Congress and are provided here for informational purposes only, as any sentencing of the defendant will be determined by the judge.

GOYAL is scheduled to be sentenced by Judge Seibel on January 6, 2022, at 2:30 p.m.            

Ms. Strauss praised the work of the Federal Bureau of Investigation, the U.S. Department of Health and Human Services, Office of Inspector General, and the Office of the Inspector General of the SBA, whose expertise and diligence were integral to the development of this investigation and the guilty plea.

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SHREVEPORT, La. - United States Attorney Brandon B. Brown announced that Marty T. Johnson and Keesha Dinkins were both sentenced today by United States District Judge Donald E. Walter in connection with a healthcare fraud and wire fraud scheme they were involved in.

Johnson, 59, of Shreveport, was sentenced to 60 months in prison, followed by 1 year of supervised release. Dinkins, 45, of Bossier City, was sentenced to 24 months in prison, followed by 1 year of supervised release. In addition, Johnson and Dinkins were ordered to jointly pay restitution in the amount of $3,500,000.

On October 26, 2021, Johnson and Dinkins each entered guilty pleas in connection with the case. Johnson pleaded guilty to a Bill of Information charging him with conspiracy to commit healthcare fraud and wire fraud. Dinkins pleaded guilty to a Bill of Information charging her with misprision of a felony charge of healthcare fraud. Johnson and Dinkins each admitted to defrauding the Medicaid Program out of $3.5 million.

According to information presented to the court, Johnson owned and operated Positive Change Counseling Agency (Positive Change) located in Shreveport, Louisiana, from January 2013 to January 2018. Keesha Dinkins was a manager and supervisor at Positive Change. Positive Change provided mental health rehabilitation and related services to Medicaid beneficiaries in the Caddo and Bossier Parish areas. From 2014 to January 2018, Johnson submitted and caused to be submitted fraudulent claims for mental health rehabilitation and non-emergency transportation services on behalf of Positive Change. Dinkins knew that Johnson submitted these fraudulent claims which she and Johnson both knew were not performed or rendered. These fraudulent claims resulted in Positive Change receiving payments from Medicaid to which it was not entitled.

Johnson admitted to paying individuals money to enroll with Positive Change, increasing the capacity for Positive Change to bill Medicaid for services that were not rendered. Johnson instructed employees, and Dinkins supervised those employees, at Positive Change to create false client files to conceal from Medicaid and insurance company auditors and inspectors that it had not performed the services related to its previously submitted claims which had already been reimbursed by Medicaid. In order to create these false client files, sections from different client documents were physically cut to create inserts which were glued into blank client log templates. These templates with the glued inserts were then photocopied to create the appearance of legitimate documents. Johnson and Dinkins supervised and knowingly and willfully instructed the employees that were creating these false client files to place the false and fictitious photocopied, cut and pasted, documents into the client files. Johnson and Dinkins knew that these false client files were used to conceal from Medicaid officials that Positive Change did not render the services in the claims submitted by it and paid by Medicaid.

In addition, Johnson knowingly caused Positive Change to use Medicaid recipients’ names and identification information without their knowledge or consent to submit fraudulent claims for mental health rehabilitation and non-emergency transportation.

The case was investigated by the U.S. Department of Health and Human Services–Office of Inspector General, Louisiana State Attorney General’s Office-Medicaid Fraud Control Unit, and Federal Bureau of Investigation. Assistant U.S. Attorney Earl M. Campbell prosecuted the case.

If you have any information pertaining to this or any other type of Medicaid fraud, please contact the U.S. Department of Health and Human Services–Office of Inspector General at 1-800-HHS-TIPS (1-800-447-8477) or the Louisiana Medicaid Fraud Hotline at 1-800-488-2917.

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Conspired with Owner of Tennessee Genetic Testing Laboratory, Marketing Companies, and Physicians to Defraud the United States

NASHVILLE – A Kentucky woman pleaded guilty yesterday in U.S. District Court in Nashville, to conspiracy to pay and receive health care kickbacks, announced Acting U.S. Attorney Mark H. Wildasin for the Middle District of Tennessee.

Elizabeth Turner, 34 of Glenview, Kentucky, was charged by criminal Information in November with conspiring with Fadel Alshalabi, the owner of Crestar Labs, LLC, based in Spring Hill, Tennessee, Melissa Lynn “Lisa” Chastain, the owner of marketing company Genetix, LLC, located in Belton, South Carolina, as well as other marketers and physicians, to offer, pay, solicit and receive illegal kickbacks and to defraud the Medicare and Medicaid Programs.

Between approximately February 2018 and ending around August 2019, Turner was the owner of telemedicine company Advanced Tele-Genetic Counseling (“ATGC”), which received kickback payments from marketers in exchange for providing signed doctors’ orders for Cancer genomic (“CGx”) testing. CGx testing uses DNA sequencing to detect mutations in genes that could indicate a higher risk of developing certain types of cancers in the future. CGx testing is not a method of diagnosing whether an individual presently has cancer. The marketers targeted Medicare and Medicaid patients through door-to-door marketing, at senior citizen fairs, at nursing homes, and at other locations, and convinced patients to provide their genetic material via a mouth swab kit. The marketers then provided the swab kits to Crestar Labs for CGx testing in exchange for kickbacks paid by Crestar Labs. Crestar Labs billed Medicare and Medicaid for the tests.

Turner, through ATGC, paid kickbacks to doctors for signed orders for CGx tests, without regard for the medical necessity of the tests. Turner knew the doctors were not the patients’ treating physicians, were not treating the patients for any specific medical problem, symptom, illness, or diagnosis, and were not using the results in the care of the patients. Turner was aware that the doctors often never contacted the patients at all.

As a result of Turner’s involvement in the conspiracy, ATGC received approximately $234,730 in illegal kickback payments from marketing company co-conspirators, including Genetix, LLC. As a result of the conspiracy, Medicare and Medicaid paid laboratories, including Crestar Labs, LLC millions of dollars in reimbursements they were not entitled to receive because the CGx tests had been procured through the payment of kickbacks, and were otherwise ineligible for reimbursement.

Turner faces up to five years in prison when she is sentenced on May 2, 2022, and a fine of up to $250,000; restitution to the Medicare and Medicaid programs; and forfeiture of the ill-gotten proceeds.

This case was investigated by the U.S. Department of Health and Human Services - Office of the Inspector General, and the Federal Bureau of Investigation. Assistant U.S. Attorneys Sarah K. Bogni and Robert S. Levine are prosecuting the case.

United States v. Elizabeth Turner is docketed at Criminal Case No. 3:21-cr-00280.

United States v. Fadel Alshalabi, Edward Klapp, and Melissa Lynn Chastain is docketed at Criminal Case No. 3:21-cr-00171. The charges contained in that Superseding Indictment are merely accusations. The defendants are presumed innocent until proven guilty in a court of law.

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A federal jury convicted a Tennessee physician and his wife yesterday in the Northern District of Alabama for unlawfully distributing opioids, providing unnecessary services and defrauding insurers from their now-shuttered Alabama clinics.  

According to court documents and evidence presented at trial, Mark Murphy, 65, and his wife, Jennifer Murphy, 65, both of Lewisburg, owned and operated North Alabama Pain Services (NAPS), which closed its Decatur and Madison offices in early 2017. Over the approximately five-year period leading up to the clinic closing its Alabama locations, Murphy and his wife, who was the office manager, caused over $50 million in fraudulent or unnecessary medical services to be charged to Medicare, TRICARE, Blue Cross Blue Shield of Alabama and others. Evidence at trial showed that NAPS provided pre-signed prescriptions to thousands of patients a month, including prescriptions written outside the usual course of professional practice without a legitimate medical purpose. The Murphys also solicited and received unlawful payments for referring fraudulent or unnecessary services to patients. Jennifer Murphy was also convicted of tax-related charges for underreporting clinic income.

Both defendants were convicted of conspiracy to unlawfully distribute controlled substances and conspiracy to commit health care fraud, along with various substantive counts related to the same. They were also convicted of conspiring to defraud the United States and receiving kickbacks. The Murphys face a maximum of 20 years in prison for the drug charges and a maximum of 10 years in prison for the health care fraud charges. Both defendants face a maximum of five years in prison for charges stemming from violations of the Anti-Kickback Statute, and Jennifer Murphy faces up to three years in prison for the tax charges. A federal district court judge will determine any sentence after considering the U.S. Sentencing Guidelines and other statutory factors. Sentencing is scheduled for June 30.

Assistant Attorney General Kenneth A. Polite Jr. of the Justice Department’s Criminal Division; U.S. Attorney Prim F. Escalona for the Northern District of Alabama; Special Agent in Charge Bradford L. Byerly of the Drug Enforcement Administration (DEA) New Orleans Field Division; Special Agent in Charge Johnnie Sharp Jr. of the FBI Birmingham Division; Special Agent in Charge James E. Dorsey of IRS Criminal Investigation (IRS-CI) Atlanta Field Office; and Special Agent in Charge Tamala E. Miles of the Department of Health and Human Service Office of the Inspector General (HHS-OIG) Atlanta Region made the announcement.

FBI, HHS-OIG, IRS-CI and DEA investigated the case.

Assistant Chief Jillian Willis and Trial Attorney Emily Gurskis of the Criminal Division’s Fraud Section and Assistant U.S. Attorney J.B. Ward of the Northern District of Alabama are prosecuting the case.

The Fraud Section leads the Appalachian Regional Prescription Opioid (ARPO) Strike Force. Since its inception in October 2018, the ARPO Strike Force, which operates in 10 districts, has charged more than 90 defendants who are collectively responsible for distributing more than 105 million pills. The ARPO Strike Force is part of the Health Care Fraud Strike Force Program, which since March 2007 has charged more than 4,200 defendants who collectively have billed the Medicare program for more than $19 billion. In addition, the Centers for Medicare & Medicaid Services, working in conjunction with the Office of the Inspector General for the Department of Health and Human Services, are taking steps to hold providers accountable for their involvement in health care fraud schemes. More information can be found at:https://www.justice.gov/criminal-fraud/health-care-fraud-unit.

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A Pakistani man was sentenced today in the Northern District of Illinois for a health care fraud scheme and money laundering conspiracy.

Muhammad Ateeq, 33, of Rawalpindi, Pakistan, was sentenced to 12 years in prison and ordered to pay approximately $48 million in restitution. In addition, Judge Manish Shah ordered the forfeiture of a $2.4 million cashier’s check and over $1 million in cash.

According to court documents, Ateeq worked in the Islamabad office of Home Health Care Consulting, an entity that controlled Medicare billing and maintenance of electronic medical records for over 20 home health agencies located in Illinois, Indiana, Nevada and Texas. While working at Home Health Care Consulting, Ateeq used a variety of fake identities, including “Nilesh Patel,” “Sanjay Kapoor” and “Rajesh Desai,” to acquire and manage home health agencies in the United States. Once the agencies were under Ateeq’s control, Ateeq caused the agencies to submit fraudulent claims to Medicare for home health services, resulting in over $40 million in payments for services that were never rendered.

As part of the money laundering conspiracy, Ateeq directed his U.S. employees to deposit checks of fraud proceeds into U.S. bank accounts designated by overseas customers of overseas money transmitting businesses. The money transmitting businesses then issued cash payments to Ateeq in Pakistan, as well as deposits into bank accounts in Pakistan under Ateeq’s control. Ateeq also directed U.S. employees to use fraud proceeds to purchase expensive watches and other luxury items in the United States and then deliver the items to Ateeq’s associates in Dubai.

Assistant Attorney General Kenneth A. Polite Jr. of the Justice Department’s Criminal Division; U.S. Attorney John R. Lausch, Jr. for the Northern District of Illinois; Assistant Director Luis Quesada of the FBI’s Criminal Investigative Division; Special Agent-in-Charge Emmerson Buie Jr. of the FBI Chicago Field Office; and Principal Deputy Inspector General Christi A. Grimm of the U.S. Department of Health and Human Services Office of Inspector General (HHS-OIG) made the announcement.

The FBI Chicago Field Office and HHS-OIG investigated the case.

Trial Attorney Sarah Wilson Rocha of the Criminal Division’s Fraud Section and Assistant U.S. Attorneys Jeremy Daniel and Patrick Mott of the Northern District of Illinois prosecuted the case.

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A New York woman was sentenced today to 78 months in prison for defrauding health care programs, including more than $6.5 million from Medicare Part D plans and Medicaid drug plans.

According to court documents, Aleah Mohammed, 37, of Queens, pleaded guilty to one count of mail fraud, one count of health care fraud, and one count of conspiracy to commit health care fraud.

According to court documents, Mohammed was an owner and operator of five pharmacies: Superdrugs Inc., Superdrugs I Inc., Superdrugs II Inc., S&A Superdrugs II Inc. and Village Stardrugs Inc. Between 2015 and 2020, Mohammed used these pharmacies to defraud health care programs, including Medicare and Medicaid, by submitting claims for prescription drugs that were not dispensed, not prescribed as claimed, not medically necessary, or that were purportedly dispensed during a time when the pharmacy was no longer registered with the State of New York. The fraudulent claims included claims for expensive prescription drugs for the treatment of the human immunodeficiency virus (HIV). Mohammed used proceeds of the scheme to purchase herself luxury items, such as jewelry and a Porsche.

Assistant Attorney General Kenneth A. Polite, Jr. of the Justice Department’s Criminal Division; U.S. Attorney Breon Peace for the Eastern District of New York; Special Agent in Charge Scott J. Lampert of the U.S. Department of Health and Human Services Office of Inspector General’s (HHS-OIG) Office of Investigations; Assistant Director Luis Quesada of the FBI's Criminal Investigative Division; and Assistant Director-in-Charge Michael J. Driscoll of the FBI’s New York Field Office made the announcement.

HHS-OIG and the FBI investigated the case.

Trial Attorneys Andrew Estes and Patrick J. Campbell of the Criminal Division’s Fraud Section prosecuted the case.

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A New York physician was charged in an indictment unsealed today in the Eastern District of New York for an alleged $10 million health care fraud scheme involving the submission of false and fraudulent claims to Medicare and Medicare Part D plans.

According to court documents, Elemer Raffai, 56, of Rome, between approximately July 2016 and June 2017, allegedly signed prescriptions and order forms via purported telemedicine services for durable medical equipment (DME) that were not medically necessary. Raffai caused these claims to be submitted based solely on a short telephone conversation for beneficiaries he did not physically examine and evaluate and that were induced, in part, by the payments of bribes and kickbacks to Raffai. The indictment further alleges that Raffai, with others, submitted or caused the submission of approximately $10 million in false and fraudulent claims to Medicare for DME, and Medicare paid more than $4 million on those claims.

Raffai is charged with health care fraud. He was arrested and is making his initial court appearance today in the U.S. District Court for the Northern District of New York. If convicted, Raffai faces a maximum total penalty of 10 years in prison. A federal district court judge will determine any sentence after considering the U.S. Sentencing Guidelines and other statutory factors.

Assistant Attorney General Kenneth A. Polite, Jr. of the Justice Department’s Criminal Division; U.S. Attorney Breon Peace for the Eastern District of New York; Special Agent in Charge Scott J. Lampert of the U.S. Department of Health and Human Services Office of Inspector General’s (HHS-OIG) Office of Investigations; Assistant Director Luis Quesada of the FBI’s Criminal Investigative Division; and Special Agent in Charge Janeen DiGuiseppi of the FBI’s Albany Field Office made the announcement.

HHS-OIG and the FBI investigated the case.

Trial Attorneys Kelly M. Lyons and Andrew Estes of the Criminal Division’s Fraud Section prosecuted the case.

An indictment is merely an allegation, and all defendants are presumed innocent until proven guilty beyond a reasonable doubt in a court of law.

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A New York physician was charged in an indictment unsealed today in the Eastern District of New York for an alleged $10 million health care fraud scheme involving the submission of false and fraudulent claims to Medicare and Medicare Part D plans.

According to court documents, Elemer Raffai, 56, of Rome, between approximately July 2016 and June 2017, allegedly signed prescriptions and order forms via purported telemedicine services for durable medical equipment (DME) that were not medically necessary. Raffai caused these claims to be submitted based solely on a short telephone conversation for beneficiaries he did not physically examine and evaluate and that were induced, in part, by the payments of bribes and kickbacks to Raffai. The indictment further alleges that Raffai, with others, submitted or caused the submission of approximately $10 million in false and fraudulent claims to Medicare for DME, and Medicare paid more than $4 million on those claims.

Raffai is charged with health care fraud. He was arrested and is making his initial court appearance today in the U.S. District Court for the Northern District of New York. If convicted, Raffai faces a maximum total penalty of 10 years in prison. A federal district court judge will determine any sentence after considering the U.S. Sentencing Guidelines and other statutory factors.

Assistant Attorney General Kenneth A. Polite, Jr. of the Justice Department’s Criminal Division; U.S. Attorney Breon Peace for the Eastern District of New York; Special Agent in Charge Scott J. Lampert of the U.S. Department of Health and Human Services Office of Inspector General’s (HHS-OIG) Office of Investigations; Assistant Director Luis Quesada of the FBI’s Criminal Investigative Division; and Special Agent in Charge Janeen DiGuiseppi of the FBI’s Albany Field Office made the announcement.

HHS-OIG and the FBI investigated the case.

Trial Attorneys Kelly M. Lyons and Andrew Estes of the Criminal Division’s Fraud Section prosecuted the case.

An indictment is merely an allegation, and all defendants are presumed innocent until proven guilty beyond a reasonable doubt in a court of law.

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PITTSBURGH, Pa. – A resident of Pittsburgh, Pennsylvania, was sentenced in federal court for conspiracy to defraud the Pennsylvania Medicaid program, health care fraud, and aggravated identity theft, United States Attorney Cindy K. Chung announced today.

United States District Judge Cathy Bissoon sentenced Tamika Adams, 45, to sixty-five months of imprisonment, followed by two years of supervised release, for her role in a years-long conspiracy. Adams was also ordered to pay restitution to the Pennsylvania Medicaid program in the amount of $445,131.67.

During her plea hearing on March 13, 2020, Adams admitted that at various times between 2011 and 2014 she was an employee of three related entities operating in the home health care industry—Moriarty Consultants, Inc. (MCI), Activity Daily Living Services, Inc. (ADL), and Everyday People Staffing, Inc. (EPS). MCI, ADL, and a fourth entity, Coordination Care, Inc. (CCI), were approved under the Pennsylvania Medicaid program to offer certain services to qualifying Medicaid recipients (“consumers”), including personal assistance services (PAS), service coordination, and non-medical transportation, among other services. EPS nominally performed back-office functions for MCI, ADL, and CCI.

Between January 2011 and the defendant’s departure from the entities in and around 2014, MCI, ADL, and CCI collectively received tens of millions of dollars in Medicaid payments based on claims submitted for home health services, with PAS payments accounting for the vast majority of the total amount. During that time, Adams admitted that she participated in a wide-ranging conspiracy to defraud the Pennsylvania Medicaid program for the purpose of obtaining millions of dollars in illegal Medicaid payments through the submission of fraudulent claims for services that were never provided to the consumers identified on the claims, or for which there was insufficient or fabricated documentation to support the claims.

As part of the conspiracy, Adams admitted that she fabricated timesheets to reflect the provision of in-home PAS care that, in fact, she never provided to the consumer identified on the timesheets. In one instance, Adams admitted submitting false timesheets claiming that she provided more than 80 hours of care in a single week to a consumer, while also working full-time as the nominal president of ADL. During a two-year period in which the same consumer lived with Adams, the defendant admitted taking steps to conceal their co-habitation and the fact that she served as the consumer’s power of attorney (both disqualifying circumstances) from the Medicaid program.

Likewise, Adams admitted that she paid kickbacks to at least one consumer—her spouse at the time—in exchange for his participation in the scheme. Specifically, Adams admitted that she and her father, co-defendant Tony Brown, used Brown’s name on time sheets for fabricated care of Adams’s then-spouse. At various times, Adams admitted that she, Tony Brown, and her spouse would meet at an MCI office on the day that Brown received payment for the fraudulent care so that the three individuals could divide the proceeds. In total, Adams acknowledged causing losses to the Pennsylvania Medicaid program in excess of $250,000 related to her spouse.

Adams also admitted that during the conspiracy, she caused the submission of Medicaid claims for PAS care that her friend, an MCI employee, purportedly provided to various consumers, without the friend’s knowledge and when in fact no such care had been provided to the consumers. During this time, Adams admitted that her friend was recovering from a serious injury and unable to work. Adams further misused her friend’s personally identifiable information to obtain and misappropriate the resulting salary payments. Finally, Adams admitted that during the course of audits of MCI, ADL, and CCI, she fabricated documentation for submission to state authorities in an effort to conceal the Medicaid fraud scheme. Among other things, Adams fabricated PAS timesheets, criminal history checks for attendants, child-abuse clearance forms for attendants, and certain consumer affidavits to ensure that files requested as part of the audits appeared complete.

To date, a total of sixteen defendants have been charged in connection with this investigation. Adams was the twelfth defendant to enter a guilty plea. The remaining defendants, including Tony Brown, are presumed innocent unless and until proven guilty.

Assistant United States Attorney Eric G. Olshan and Special Assistant United States Attorney Edward Song are prosecuting this case on behalf of the government. The Federal Bureau of Investigation, Pennsylvania Office of the Attorney General – Medicaid Fraud Control Unit, Internal Revenue Service – Criminal Investigation, U.S. Department of Health and Human Services – Office of Inspector General, and United States Postal Inspection Service conducted the investigation.

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Acting U.S. Attorney Michelle M. Baeppler announced that William Bauer, 85, of Port Clinton, Ohio, was sentenced today by U.S. District Judge Jack Zouhary to 5 years in prison and was ordered to pay $464,099.14 in restitution, of which $253,300.55 will be paid to Medicare and $210,798.59 to Medicaid. In addition, Judge Zouhary ordered Bauer to pay $100,000 in community restitution. The community restitution will be distributed 65% to the Ohio Attorney General, Crime Victim Services Section, and 35% to the Ohio Department of Mental Health & Addiction Services. The Court strongly recommended that the community restitution amount go to the Mental Health and Recovery Services Board of Seneca, Ottawa, Sandusky and Wyandot Counties.

Judge Zouhary pronounced the sentence after Bauer was convicted at trial of 76 counts of distribution of controlled substances and 25 counts of health care fraud.

“This defendant unnecessarily distributed dangerous and highly addictive controlled substances and repeatedly ignored warning signs that his actions were causing detrimental harm to his patients and the community,” said Acting U.S. Attorney Michelle M. Baeppler. “No matter your title, those who flood the streets with dangerous drugs and prey upon vulnerable individuals will answer for their actions.”

“Criminal misconduct within the healthcare system is harmful and destructive,” said FBI Special Agent in Charge Eric B. Smith. “Not only does healthcare fraud impact insurers through monetary loss, but also to physicians, hospitals, and taxpayers who were unwitting participants to the deceitful actions. We will continue to work diligently to uncover fraudulent schemes that risk public health.”

“The sentencing of William Bauer demonstrates our commitment to stopping those who fuel the opioid epidemic,” said Kent R. Kleinschmidt, Acting Special Agent in Charge of the U.S. Drug Enforcement Administration’s Detroit Field Division. “Medical professionals who disregard their oath and instead seek to profit at the expense of their patients and community will be brought to justice.”

According to court documents and evidence presented at trial, between 2007 and 2019, Bauer, at his practice in Bellevue, Ohio, repeatedly prescribed medically unnecessary controlled substances, including Oxycodone, Fentanyl, Morphine and Tramadol, outside the usual course of professional practice and not for a legitimate medical purpose.

During the trial, prosecutors showed that Bauer prescribed high doses of opioids and other controlled substances to patients without regard to any improvement in pain level, function, or quality of life; prescribed dangerous drug combinations; failed to consider a patient’s state of addiction and ignored warning signs of abuse and diversion such as patients’ stealing medications, frequently requesting early refills, losing medications and other actions.

The case focused on Bauer’s treatment of 14 patients. Throughout the trial, prosecutors showed that these patients suffered a loss of employment, fractured families and experienced deteriorating mental health conditions as a result of their drug dependency. In one instance, court documents state that in 2015 a patient of Dr. Bauer died from an accidental overdose.

In addition to his conviction for distributing controlled substances, Bauer was also convicted of health care fraud. As part of the health care fraud scheme, Bauer billed insurers after prescribing medically unnecessary controlled substances and administered needless epidural and trigger point injections that failed to meet certain procedural requirements. Because these injections failed to meet the procedural requirements, they were rendered ineffective and fraudulently billed to insurers.

“This doctor contributed to the tidal wave of opioid overdoses that flooded our communities,” Ohio Attorney General Dave Yost said. “I am proud of the state and federal partnerships that continue to work to stem the tide of addiction.”

“Providers sow distrust in our nation’s health care system when they participate in health care fraud and activities that endanger their patients,” said Mario M. Pinto, Special Agent in Charge with the Department of Health and Human Services, Office of Inspector General. “Along with our law enforcement partners, HHS-OIG will continue to hold accountable those who threaten the safety of beneficiaries through overprescribing and engaging in health care fraud.”

Court documents state that the total loss amount to Medicare and Medicaid due to the fraudulent billing practices was $464,099.14.

This case was investigated by the Federal Bureau of Investigation, the Drug Enforcement Administration, the Department of Health and Human Services – Office of Inspector General and the Ohio Attorney General’s Office. The case is being prosecuted by Assistant U.S. Attorneys Ava R. Dustin, Michael A. Sullivan, Robert N. Melching and Payum Doroodian.

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One of the largest hospital systems in the nation and two of its doctors will pay $37.5 million to resolve violations of the False Claims Act and the California False Claims Act. The settlement is a joint resolution with the U.S. Department of Justice and the California Department of Justice.

The United States and California entered into a settlement agreement with the Prime Healthcare Services system (Prime), Prime’s Founder and Chief Executive Officer Dr. Prem Reddy, and California interventional cardiologist Dr. Siva Arunasalam to resolve alleged violations of the False Claims Act and the California False Claims Act based on kickbacks paid by Prime to Dr. Arunasalam for patient referrals. Prime includes Prime Healthcare Services Inc., based in Ontario, California; Prime Healthcare Foundation Inc.; Prime Healthcare Management Inc.; High Desert Heart Vascular Institute (HDHVI); and Desert Valley Hospital Inc. Under the settlement agreement, Dr. Arunasalam will pay $2,000,000; Dr. Reddy paid $1,775,000; and Prime paid $33,725,000. The United States will receive $35,463,057 of the settlement proceeds, and California will receive $2,036,943. Prime and Dr. Reddy paid $65 million to settle previous unrelated allegations of false claims and overbilling in 2018.

“Offering illegal financial incentives to physicians in return for patient referrals undermines the integrity of our health care system by denying patients the independent and objective judgment of their health care professionals,” said Acting Assistant Attorney General Brian M. Boynton of the Justice Department’s Civil Division. “Today’s settlement demonstrates the department’s commitment to protect federal health care programs against such violations, as well as other efforts to defraud these important programs.”

“Doctors have a sworn duty to do no harm and to put their patients’ interests first,” said Acting U.S. Attorney Tracy L. Wilkison for the Central District of California. “Kickbacks designed to increase the number of patient referrals corrupt the doctor-patient relationship and needlessly waste this nation’s health care resources.”

“In our cities and neighborhoods, hospitals are where we go for healing and care, which means they have to be a place that the people they serve can trust,” said California Attorney General Rob Bonta. “Today’s settlement should send a message that schemes like those alleged here, that put profits before people and seek to defraud our Medi-Cal program, will not be taken lightly.”

The settlement resolves allegations that:

• Prime paid kickbacks when it overpaid to purchase Dr. Arunasalam’s physician practice and surgery center because the company wanted Dr. Arunasalam to refer patients to its Desert Valley Hospital in Victorville, California. The purchase price, which was substantially negotiated by Dr. Reddy, exceeded fair market value and was not commercially reasonable. Prime also knowingly overcompensated the doctor when HDHVI entered into an employment agreement with him that was based on the volume and value of his patient referrals to Desert Valley Hospital;
• For approximately two years between 2015 and 2017, HDHVI and Dr. Arunasalam used Dr. Arunasalam’s billing number to bill Medicare and Medi-Cal for services that were provided by Dr. George Ponce, even though they knew Dr. Ponce’s Medicare and Medi-Cal billing privileges had been revoked, and that billing Dr. Ponce’s services under Dr. Arunasalam’s billing number was improper; and
• Certain Prime hospitals billed Medi-Cal, the Federal Employees Health Benefits Program and the U.S. Department of Labor’s Office of Workers’ Compensation Programs for false claims based on inflated invoices for implantable medical hardware. Dr. Arunasalam was not implicated in this conduct.

The Anti-Kickback Statute prohibits offering, paying, soliciting or receiving remuneration to induce referrals of items or services covered by a federal health care program, such as Medicare, Medicaid or TRICARE. Claims submitted in violation of the Anti-Kickback Statute may give rise to liability under the False Claims Act.

In connection with the settlement, Prime and Dr. Reddy entered into a five-year Corporate Integrity Agreement (CIA) with the U.S. Department of Health and Human Services Office of Inspector General (HHS-OIG). The CIA requires, among other things, that Prime maintain a compliance program and hire an Independent Review Organization to review arrangements entered into by or on behalf of its subsidiaries and affiliates.

“Federal healthcare funds are integral to the provision of necessary medical services to beneficiaries across the country,” said Special Agent in Charge Timothy B. DeFrancesca of the Office of Inspector General for the U.S. Department of Health and Human Services. “Therefore, we will address any actions, including those alleged in this case, that could compromise the system on which many patients rely. We will continue working with federal and state prosecutors to guard taxpayer funds that support these vital programs.”

The civil settlement includes the resolution of claims brought under the qui tam or whistleblower provisions of the False Claims Act in two lawsuits filed in federal court in Los Angeles. One suit was filed by Martin Mansukhani, a former Prime executive. The second suit was filed by Marsha Arnold and Joseph Hill, who were formerly employed in the billing office at Shasta Regional Medical Center, a Prime hospital in Redding, California. Under the qui tam provisions of the False Claims Act, a private party can file an action on behalf of the United States and receive a portion of any recovery. Although the United States did not intervene in these cases, it continued to investigate the whistleblowers’ allegations and helped to negotiate the settlement announced today. Mr. Mansukhani will receive $9,929,656 as his share of the federal government’s recovery. The cases are United States and the State of California ex rel. Martin Mansukhani v. Prime Healthcare Services, Inc., et al., 5:18-cv-00371-RGK (C.D. Cal.); and United States and the State of California ex rel. Marsha Arnold and Joseph Hill v. Prime Healthcare Services, Inc., et al., 5:18-cv-02124-FLA (C.D. Cal.).

The resolutions obtained in these matters were the result of a coordinated effort between the Civil Division’s Commercial Litigation Branch, Fraud Section; the U.S. Attorney’s Office for the Central District of California; the California Attorney General’s Office’s Division of Medi-Cal Fraud and Elder Abuse; and HHS-OIG.

The investigation and resolution of this matter illustrate the government’s emphasis on combating health care fraud. One of the most powerful tools in this effort is the False Claims Act. Tips and complaints from all sources about potential fraud, waste, abuse and mismanagement can be reported to the Department of Health and Human Services at 800-HHS-TIPS (800-447-8477).

The cases were handled for the United States by Senior Trial Counsel Marie V. Bonkowski of the Civil Division and Assistant U.S. Attorneys Jack D. Ross and Abraham C. Meltzer of the Central District of California.  

The claims resolved by the settlement are allegations only, and there has been no determination of liability.

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People with more severe obstructive sleep apnea and reductions in blood oxygen concentrations are more likely to have elevated concentrations of triglycerides in the blood, according to new research.

“Obstructive sleep apnea (OSA) is a syndrome characterized by partial or complete obstruction of the upper airways, resulting in intermittent hypoxia, variably accompanied by sleep fragmentation and daytime sleepiness,” said Professor Gary Wittert, from the Freemasons Centre for Male Health and Well-Being at the University of Adelaide and his colleagues.

“In male participants of the Swiss HypnoLaus cohort, the prevalence of moderate-to-severe OSA was 49.7%, with 74.7% men aged 40 or over having OSA syndrome.”

“However, OSA is often underdiagnosed and unrecognized in clinical settings.”

“OSA has been implicated in the development of cardiovascular conditions, however, OSA during rapid eye movement (REM) sleep and the resultant nocturnal hypoxemia are also longitudinally associated with cardiovascular disease and associated risk factors such as hypertension, insulin resistance, metabolic syndrome, and carotid atherosclerosis.”

“Animal models suggest that this increased cardiovascular risk is the result of intermittent hypoxemia leading to activation of the sympathetic nervous system, increased oxidative stress and systemic inflammation.”

“Furthermore, chronic intermittent hypoxia reduced clearance of triglyceride-rich lipoproteins and inhibited adipose tissue lipoprotein lipase activity.”

“The results of our study are concerning because the most striking effects were seen in people who were not overweight.”

The study involved 753 people from the Men Androgens Inflammation Lifestyle Environment and Stress Study (MAILES), a comprehensive assessment of the health of Australian men aged 40 and over.

Half of the participants were shown to have moderate to severe OSA, with 75% of men aged 40 or over having some form of the syndrome.

“The key message from this study is that testing for OSA should be considered even in lean men with elevated blood triglycerides concentrations,” Professor Wittert said.

The authors believe continuous positive airway pressure therapy (CPAP) delivered via machine overnight may be beneficial in reducing concentrations of triglycerides and the symptoms of OSA.

“Further studies are needed to evaluate the relationship between OSA and triglycerides in women and young men and assess the effectiveness of CPAP treatment for these groups,” Professor Wittert said.

The team’s paper was published in the journal Nature and Science of Sleep.

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WASHINGTON — After years of inaction, lawmakers and advocates in 2018 rallied around an ambitious plan to modernize the sprawling, government-run health care system for Veterans, which still treats many patients in hospital wards built before World War II.

A commission, mandated that year by Congress, was tasked with weighing recommendations from the Department of Veterans Affairs for each of its 1,200 hospitals and clinics across the country and holding hearings in affected communities. The southward migration of Veterans from the Northeast and Midwest, the shift from costly inpatient to outpatient care and the age of each building would factor into whether facilities would be urged to close, reduce service or shift patients into private care. VA would finally catch up to modern private hospitals, saving billions of dollars it spends each year to shore up its aging health care facilities, proponents of the plan argued.

But a long-sought realignment of the country’s largest health care system was killed this week by bipartisan political resistance through a short news release from 12 senators who said they would not approve the nine nominees up for confirmation to establish the Asset and Infrastructure Review (AIR) Commission. And a costly four-year effort to reposition VA in an increasingly competitive health care market fell victim to the principle that, just as all politics is local, so, apparently, is any decision to shift services for a constituency as crucial as Veterans.

The lawmakers indicated that the politically explosive recommendations VA made in March made moving forward impractical.

“We share a commitment to expanding and strengthening modern VA infrastructure in a way that upholds our obligations to America’s Veterans,” the senators, led by Senate Veterans’ Affairs Committee Chairman Jon Tester, D-Mont., wrote in their release Monday. “We believe the recommendations put forth to the AIR Commission are not reflective of that goal, and would put Veterans in both rural and urban areas at a disadvantage.” The release said lawmakers were committed to a “continued push” to help VA invest in “21st century [health-care] facilities” for Veterans.

Lawmakers in both parties had expressed misgivings about a process they felt was flawed from the start. The data VA relied on to assess the hospitals was several years old and collected before the coronavirus pandemic, potentially skewing the number of patients and physicians in a community to appear lower than they really were.

The White House also was slow to nominate the nine-member commission, with the final member announced only last week. That left a too-tight window to complete its work by an early 2023 deadline, lawmakers argued, as well as uncertainty about whether a nominee would face pressure to weigh in on the recommendations in order to be confirmed.

But by halting the commission and the sweeping plan released by VA Secretary Denis McDonough with recommendations to build about 80 new clinics, hospitals and nursing homes of varying sizes and close a net of three major hospitals and dozens of clinics with unused inpatient beds, the lawmakers left the agency with no blueprint to modernize its aging system, current and former officials said.

“President Biden has insisted that our Veterans in the 21st century should not be forced to receive care in early 20th century buildings,” Melissa Bryant, VA’s acting assistant secretary for public and intergovernmental affairs, said in an email. She noted that the median age of VA hospitals is nearly 60 years. “Whatever Congress decides to do with the AIR Commission, we will continue to fight for the funding and modernization that our Veterans deserve,” Bryant wrote.

VA leaders going back years have said they are burdened by the need to maintain as many as 1,000 underused clinics and hospitals, some of which have more staff than patients, at significant cost. Closing them would require approval from Congress.

When the commission was created as part of the larger Mission Act, conservatives said the government would reduce wasteful expenses and shift more Veterans’ health care to the private sector. Democrats, including McDonough, embraced the possibility of caring for more Veterans in communities where they’re moving.

“We saw it as an opportunity,” said one VA official, who spoke on the condition of anonymity to discuss a sensitive issue. In a commitment to new investment, President Joe Biden requested about $18 billion in new money for VA construction in an early version of his infrastructure plan, although the money was eventually left out of the law.

But even before McDonough released his recommendations, members of Congress who were briefed on possible reductions to service in their districts went on the offensive, some holding rallies in opposition, others issuing defiant statements that previewed the battle to stave off reductions. The American Federation of Government Employees, the union representing more than 200,000 VA staff, pressured Democratic allies in Congress to oppose feared job losses. Republicans, most of whom voted for the Mission Act, became sensitive to local concerns that Veterans would lose access to doctors, as the plan called for closing or rebuilding 35 large hospitals in 21 states.

“It’s a total lack of courage,” Robert McDonald said of the decision to kill the commission, citing the midterm elections in November. “It’s obvious what’s behind it. There’s an election coming up. Elections are local.”

McDonald, who was VA secretary for several years under President Barack Obama, had tried to close a sparsely used hospital in South Dakota, only to see the Trump administration cancel the plan soon after taking office following objections from Sen. Mike Rounds, R-S.D.

Robert Wilkie, President Donald Trump’s second VA secretary, also expressed disappointment with this week’s decision. “We have to build a VA where the Veterans live now, not where they lived in 1945,” he said in a text message. “The VA dollar is being stretched to the breaking point and dissolving the commission does not help.”

It’s unclear if lawmakers who still support the commission have any options. Rep. Mike Bost, R-Ill., who with Sen. Jerry Moran, R-Kan., opposed the decision, said in a statement Wednesday that he is “still assessing how to move forward “as the law requires.”

“The fact remains that there is a serious and growing mismatch between the VA health care system as we know it today and how, and where, it needs to evolve for the future,” Bost wrote.

Darin Selnick, a senior adviser for Concerned Veterans for America who led efforts at VA and later the Trump White House to create the commission, said the Biden administration left VA to issue recommendations with no structure to Vet them, opening the process to political resistance.

“Anytime a legislator hears they might close a facility in their district they go ballistic,” Selnick said, “but if you had had a commission in place that wouldn’t have mattered.” He emphasized that VA’s plan “was only a set of recommendations” that could have been changed.

An official with the American Legion predicted dire consequences of inaction.

“Veterans are going to lose,” said Chanin Nuntavong, the group’s executive director of government and Veteran affairs. “Old infrastructure needs to be repaired or replaced. Veterans’ care will be degraded by a lack of technology and unsanitary conditions while construction costs go through the roof.”

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Columbia, South Carolina --- Acting United States Attorney M. Rhett DeHart announced today that seven criminal defendants have pleaded guilty to charges related to a Medicaid fraud conspiracy arising from the false billing of behavioral health services for children.

The defendants are all former owners, employees, or business associates of Wrights Care Services, LLC, a North Carolina-based provider of rehabilitative behavioral health services. Today’s guilty plea of former owner Daniel Wright marks the seventh guilty plea in the case, the result of a years-long investigation and prosecution led by the United States Attorney’s Office and Federal Bureau of Investigation (FBI) in cooperation with the South Carolina Attorney General’s Office.

“Health care fraud will be prosecuted to the fullest extent of the law.” said Acting U.S. Attorney DeHart. “It is a betrayal of public trust and diverts scarce resources from Americans who need health care coverage.”

“For several years, Wright and the other defendants took advantage of Medicaid, which benefits over one million low-income South Carolinians,” said Susan Ferensic, Special Agent in Charge of the FBI Columbia Field Office. “Healthcare fraud continues to be at the forefront of crimes our office investigates, and this case should serve as an example to individuals and businesses that these schemes will not be tolerated.”

“Not only did this fraud scheme steal millions of dollars from our hardworking taxpayers, it took that money away from legitimate programs to help children who needed it,” South Carolina Attorney General Alan Wilson said. “This case is another example of the close and productive working relationship our office has with the U.S. Attorney’s Office and the FBI and I want to commend them for their diligence in this case.”

Evidence obtained in the investigation revealed that, in 2014, Wrights Care Services was approved by South Carolina Medicaid to provide behavioral health services. Wrights Care maintained associated franchise locations throughout South Carolina, including Columbia, Spartanburg, Pickens, Cheraw, Society Hill, Bennettsville, Hartsville, and Conway. From its inception, Wrights Care Services failed to provide qualified behavioral health services to the children in its care. Nevertheless, in order to receive payment from Medicaid, members of the conspiracy submitted inflated bills and false medical records. In the case of one franchise, members of the conspiracy began billing Medicaid for services before the franchise opened its doors.

In 2015, South Carolina Medicaid sought to audit Wrights Care Services, and members of the conspiracy met in Columbia at a “note party” to forge signatures and falsify records to support the audit. During the course of the scheme, Wrights Care and its affiliated franchises submitted bills to Medicaid in the amount of $6,657,810.43.

The following defendants have pleaded guilty so far:

• Daniel Wright, 39, of Greensboro, North Carolina
• Glenn Pair, 35, of Baltimore, Maryland
• John David Zachariah Wallace, 40, of Sugar Land, Texas
• Kathleen Dubose, 54, of Greensboro, North Carolina
• Sherel Lawson, 47, of Summerfield, North Carolina
• Latasha Bethea, 37, of Fayetteville, North Carolina
• Tonya Strickland Hall, 47, of Greensboro, North Carolina

Each defendant faces a maximum penalty of five years in federal prison for conspiracy to defraud the United States. Each defendant also faces a fine of up to $250,000 and 3 years of supervision to follow the term of imprisonment. United States District Judge Mary G. Lewis accepted the guilty pleas and will sentence the defendants after receiving and reviewing presentencing reports prepared by the United States Probation Office.

This case was investigated by Special Agents Neil Power and Mark McMahon of the FBI, and Assistant Attorney General Brent Yandle and Assistant Chief Investigator Jamie Seales of the South Carolina Attorney General’s Office Medicaid Fraud Control Unit. Assistant United States Attorney Brook Andrews is prosecuting the case.

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NEW ORLEANS – United States Attorney Duane A. Evans announced that BONNIE JEAN LAWLESS DIAZ (“DIAZ”) has been sentenced on January 18, 2022 to 36 months of probation after pleading guilty in federal court relating to her role in a health care fraud conspiracy.

DIAZ, age 46, a resident of Slidell, Louisiana, pled guilty on September 23, 2021 before U.S. District Judge Jay C. Zainey to Count One of a Superseding Bill of Information charging her with misprision (or knowing concealment) of the commission of a felony, in violation of Title 18, United States Code, Section 4.

According to the Indictment, in or around March 2014, continuing through in or around October 2016, co-defendants conspired to knowingly and willfully execute a scheme and artifice to defraud TRICARE, a federal health care benefit program affecting commerce, and other health care benefit programs.

According to the Superseding Bill of Information, DIAZ had knowledge of the commission of the health care fraud. DIAZ concealed the fraud by knowingly submitting or caused to be submitted compounded medications for which there was no medical necessity and did not as soon as possible make known the same to some judge or other person in civil or military authority under the United States.

The owner, on behalf of Prime Pharmacy, contracted with various entities, including Pharmacy Benefit Managers (“PBMs”), obligating Prime Pharmacy to collect copayments from beneficiaries in order to be reimbursed by various health care benefit programs, including TRICARE. Additionally, the owner of Prime worked with codefendant Donald Auzine to market the compounded medications produced by Prime Pharmacy. Auzine found other marketers outside of the state to find beneficiaries that were willing to receive medically unnecessary compounds and doctors willing to prescribe compounds without medical necessity.

Beginning in or around March 2014, and continuing through in or around April 2016, Prime Pharmacy dispensed prescriptions for High-Yield Compounded Medications to beneficiaries of TRICARE and other health care benefit programs that were not medically necessary, induced by kickback payments, or where copayments were either waived or credited by Prime Pharmacy, and accordingly, submitted or caused to be submitted false and fraudulent claims for reimbursement to TRICARE, other health care benefit programs, and PBMs.

DIAZ was also ordered to repay TRICARE $180,000 in restitution.

“Individuals involved in this scheme illegally billed TRICARE out of close to $15 million and I am pleased that the U.S. Attorney’s Office is requiring justice,” said Special Agent in Charge Cynthia Bruce, Office of Inspector General, Defense Criminal Investigative Service, Southeast Field Office. “There are no victimless crimes and DCIS agents will continue to pursue unscrupulous greedy individuals who steal from our military health care system and all taxpayers.”

“Those entrusted with providing health care services to Veterans and their family members will be held accountable should they violate that trust,” said Special Agent in Charge Jeffrey Breen of the Department of Veterans Affairs Office of Inspector General’s South Central Field Office. “The VA OIG is grateful to the United States Attorney’s Office and our law enforcement partners for their efforts to achieve justice in this case.”

U.S. Attorney Evans praised the work of the Office of Inspector General, Defense Criminal Investigative Service, the Department of Homeland Security, the Department of Veterans Affairs – Office of Inspector General, and the United States Postal Service – Office of Inspector General.

The prosecution of the case is being handled by Assistant United States Attorney Kathryn McHugh.

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Tampa, FL – U.S. District Judge Virginia Hernandez Covington today sentenced Patsy Truglia (54, Parkland) to 15 years in federal prison for his role in two consecutive conspiracies to commit health care fraud and for making a false statement in a matter involving a health care benefit program. As part of his sentence, the Court ordered Truglia to pay $18.3 million to the affected government health programs and an insurance company. The Court also entered a money judgment against Truglia in the amount of $10,117,738 and ordered him to forfeit numerous assets, including $9,308,235.86 seized from various financial accounts, high-end automobiles (Rolls Royce, Lamborghini, and Mercedes), jewelry, and Truglia’s lakefront home, all of which were traceable to the charged criminal conduct. Truglia had pleaded guilty on October 5, 2021.

According to court documents, beginning in January 2018 and continuing into April 2019, Truglia and other conspirators, including co-defendant Ruth Bianca Fernandez (who worked under Truglia’s supervision), generated medically unnecessary physicians’ orders via their telemarketing operation for certain orthotic devices—knee braces, back braces, wrist braces, and other braces—referred to as durable medical equipment (“DME”). Through the telemarketing operation, federal health care program beneficiaries’ (i.e., Medicare beneficiaries’) personal and medical information was harvested to create the unnecessary DME brace orders.

The brace orders were then forwarded to purported “telemedicine” vendors that, in exchange for a fee, paid illegal bribes to physicians to sign the orders, often without ever contacting the beneficiaries to conduct the required telehealth consultations. The fraudulent, illegal brace orders were then returned to Truglia’s telemarketing operation, which used the orders as support for millions of dollars in false and fraudulent claims submitted to the Medicare program. To avoid Medicare scrutiny, Truglia and Fernandez spread the fraudulent claims across five DME storefronts operated under Truglia’s ownership and control and Fernandez’s day-to-day management. In all, through their five storefronts, Truglia, Fernandez, and other conspirators caused approximately $25 million in fraudulent DME claims to be submitted to Medicare, resulting in approximately $12 million in payments.

On April 9, 2019, multiple federal law enforcement agencies participated in a nationwide action referred to as “Operation Brace Yourself.” The Operation targeted ongoing schemes, such as Truglia’s, in which companies were paying illegal bribes to secure signed physicians’ DME brace orders for use as support for fraudulent claims submitted to the federal programs. In the Middle District of Florida, the April 2019 Operation included, among other efforts, the execution of search warrants at several of Truglia’s DME storefronts and a civil action under which, among other ramifications, enjoined Truglia and (by extension) his five storefronts from engaging in any further health care fraud conduct.

Undeterred, beginning in or around April 2019 and continuing into July 2020, Truglia and other conspirators—some of whom had worked with Truglia in the earlier conspiracy and some of whom were new conspirators—carried out a similar conspiracy using three new DME storefronts and different “telemedicine” vendors. Through this conspiracy, Truglia and his conspirators caused an additional approximately $12 million in fraudulent DME claims to be submitted to Medicare, resulting in approximately $6.3 million in payments.

“Every defendant in this case shared a common trait—greed,” said IRS-CI Special Agent in Charge Brian Payne. “The desire for money fueled them to commit crimes against our healthcare system and prey upon those in our society who deserve our highest respect, the elderly and military Veterans. Thanks to the financial expertise and diligence of IRS-CI special agents, as well as our partner federal, state, and local law enforcement officers, these criminals are off the street and are facing the consequences of their actions.”

“The significant sentence and financial restitution imposed today reflects the serious nature of Mr. Truglia’s criminal conduct and underscores that the Government will continue to vigorously prosecute health care fraud cases and seek the recovery of all illicitly obtained assets of these greed-fueled fraud schemes,” said Special Agent in Charge Omar Pérez Aybar of HHS-OIG. “Collaborating closely with our law enforcement partners, we will continue to thoroughly investigate fraudsters who seek to enrich themselves at the expense of vulnerable members of the public.”

“We have dedicated agents and analysts focused on uncovering the deceitful tactics used to cheat our federal healthcare system,” said FBI Tampa Division Special Agent in Charge Michael McPherson. “The cost of healthcare fraud impacts all of us. The FBI will continue to engage with our partners to protect taxpayers from fraudsters like Mr. Truglia and those identified in Operation Brace Yourself.”

“The sentence imposed today holds this defendant accountable for his prominent role in a reprehensible healthcare fraud scheme involving CHAMPVA and Medicare,” said Special Agent in Charge David Spilker, Department of Veterans Affairs Office of Inspector General, Southeast Field Office. “The VA OIG is committed to ensuring healthcare spending is directed only to deserving Veterans and those who serve them. We thank and commend our outstanding law enforcement partners in this important joint investigation.”

This case was investigated by U.S. Department of Health and Human Services – Office of Inspector General, the Federal Bureau of Investigation, the Department of Veterans Affairs – Office of Inspector General, and the Internal Revenue Service –Criminal Investigation, Tampa Field Office. The criminal case was prosecuted by Assistant United States Attorneys Jay G. Trezevant, Tiffany E. Fields, and James A. Muench. The civil action is being handled by Assistant United States Attorney Carolyn B. Tapie.

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PITTSBURGH, PA - A South Hills pharmacist pleaded guilty in federal court to charges of obtaining controlled substances by fraud, misbranding of drugs, and health care fraud conspiracy, Acting United States Attorney Stephen R. Kaufman announced today.

Timothy W. Forester, 46, of Venetia, PA pleaded guilty to three counts before Senior United States District Judge David S. Cercone.

In connection with the guilty plea, the court was advised that Forester was a licensed pharmacist who owned four pharmacies – Century Square Pharmacy in West Mifflin, PA and Prescription Center Plus with locations in South Park, PA, McMurray, PA and Eight Four, PA. From on or about November 14, 2018, to on or about February 14, 2019, Forester admitted he knowingly, intentionally and unlawfully obtained oxycodone and hydrocodone, Schedule II controlled substances, by misrepresentations, fraud, and deception. Forester admitted he did not place the controlled substances into the inventories of the four pharmacies and did not maintain records to show the controlled substances were dispensed. In addition, Forester admitted he relabeled generic drugs as name brand medications and then sold them as if they were the more expensive drugs. Finally, Forester admitted filling prescriptions with generic drugs, but billing Medicare and Medicaid for the more expensive name brand drugs, thereby committing health care fraud and causing a loss to Medicare and Medicaid of approximately $680,000.

“Timothy Forester ordered opioids without adding them to inventory, mislabeled generic drugs as name-brand medications, and billed Medicare and Medicaid for name-brand drugs when he provided generics, all in violation of federal law,” said Acting U.S. Attorney Kaufman, “We will continue to pursue medical professionals who engage in fraud schemes to enrich themselves at the expense of their patients.”

“U.S. consumers rely on health care professionals to follow FDA requirements pertaining to prescription medications. When they take actions to evade these requirements, they put patient health at risk,” said Special Agent in Charge Mark S. McCormack, FDA Office of Criminal Investigations Metro Washington Field Office. “We will continue to investigate and bring to justice those who threaten the safety of the nation’s drug supply and, ultimately, the patients who take those drugs.”

“Pharmacy professionals who mishandle opioids in an effort to enrich themselves only exacerbate the challenges and devastation families and communities experience as a result of our nation's opioid epidemic," said Maureen R. Dixon, Special Agent in Charge for the Inspector General’s Office of the U.S. Department of Health and Human Services in Philadelphia. “We will continue to work with our law enforcement partners to bring unscrupulous health professionals to justice.”

“Pharmacists such as Forester have an obligation to properly dispense and safeguard controlled substances such as oxycodone and hydrocodone,” said Thomas Hodnett, Acting Special Agent in Charge of the Drug Enforcement Administration’s (DEA) Philadelphia Field Division. “Forester used his position of trust and access to obtain these powerful painkillers for his own use through fraud and deception.”

Judge Cercone scheduled sentencing for February 8, 2020 at 11:30 a.m. As to Count 1, the law provides for a maximum sentence of four years in prison, a fine of $250,000 or both. As to Count 11, the law provides for a maximum sentence of three years in prison, a fine of $250,000 or both. As to Count 12, the law provides for a maximum sentence of 10 years in prison, a fine of $250,000 or both. Under the Federal Sentencing Guidelines, the actual sentence imposed is based upon the seriousness of the offenses and the prior criminal history, if any, of the defendant.

Assistant United States Attorney Robert S. Cessar is prosecuting this case on behalf of the government.

The investigation leading to the filing of charges in this case was conducted by the Western Pennsylvania Opioid Fraud and Abuse Detection Unit, which combines personnel and resources from the following agencies to combat the growing prescription opioid epidemic: Federal Bureau of Investigation, U.S. Health and Human Services – Office of Inspector General, Drug Enforcement Administration, Internal Revenue Service-Criminal Investigations, Pennsylvania Office of Attorney General - Medicaid Fraud Control Unit, United States Postal Inspection Service, U.S. Attorney’s Office – Criminal Division, Civil Division and Asset Forfeiture Unit, Department of Veterans Affairs-Office of Inspector General, Food and Drug Administration-Office of Criminal Investigations and the Pennsylvania Bureau of Licensing.

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The United States has reached a civil settlement with Saint Francis Medical Center (Saint Francis) resolving the Government’s claims under the Controlled Substances Act. According to the United States’ allegations, Saint Francis employed a Farmington, Missouri physician, Brett Dickinson (Dickinson), who wrote prescriptions for controlled substances without legitimate medical purposes and outside the usual course of professional practice. As part of the settlement, Saint Francis agreed to pay $1,624,957.67.

The United States alleged that Saint Francis, through Dickinson’s actions in the scope of his employment, issued invalid prescriptions for opioids such as morphine, hydromorphone, and oxycodone. According to the United States’ allegations, Dickinson prescribed these opioids to patients simultaneously with muscle relaxers and benzodiazepines. The United States claimed that such drugs are known to enhance the addictive, euphoric effects of opioids and, as a result, are commonly sought-after in combination with opioids by individuals with substance abuse disorders and individuals who seek to use opioids recreationally. The United States alleged that Dickinson issued these prescriptions while ignoring warning signs of drug diversion or misuse, including aberrant urine drug test results and patients’ previous hospital treatment for medical problems related to drug misuse.

Although not part of the settlement agreement, in August 2021, Saint Francis voluntarily incorporated the Foundation for Opioid Prescribing Education in the State of Missouri. According to Saint Francis, the Foundation, which it funded with an initial contribution of $1 million, will be used to fund education programs for physicians and other healthcare professionals in Southeast Missouri on best practices in prescribing opioids and managing patients with chronic pain issues.

Saint Francis fully cooperated with the United States’ investigation of the case. Additionally, as part of the settlement, Saint Francis agreed to cooperate with the United States’ investigation of individuals not released in the settlement agreement, including by furnishing documents related to “the prescribing of controlled substances by Dickinson.”

“When Dr. Dickinson recklessly prescribed controlled substances without regard for his patients’ well-being, he violated the trust our communities extend to healthcare professionals. We appreciate the steps taken by Saint Francis Medical Center to prevent such illegal behavior by its staff in the future,” said Special Agent in Charge for the Office of Inspector General of the U.S. Department of Health and Human Services Curt L. Muller. “In coordination with our law enforcement partners, our agents will continue to investigate such fraud schemes and protect the public from unscrupulous prescribers.”

The Office of Inspector General of the Department of Health and Human Services, Drug Enforcement Administration, and the Missouri Attorney General’s Medicaid Fraud Control Unit investigated the case. Assistant United States Attorney Amy Sestric handled the case.

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Six Medical Practices and a Physician-Owner to Pay Over $7.4 Million to Resolve Claims of Improper Billing of Medicare and the Federal Employees Health Benefit Program for Acupuncture Procedures

Breon Peace, United States Attorney for the Eastern District of New York, Scott J. Lampert, Special Agent-in-Charge, U.S. Department of Health and Human Services, Office of the Inspector General, New York Region (HHS-OIG), and Norbert E. Vint, Deputy Inspector General, Office of Personnel Management (OPM), announced today that six surgery centers and medical offices affiliated with Interventional Pain Management Center P.C. (“IPMC”), a company owned by Dr. Amit Poonia, have agreed to pay $7,447,340.75 to resolve liability under the False Claims Act for claims submitted to federal health care programs for acupuncture treatment.

“This settlement holds the defendants accountable for mischaracterizing acupuncture as a surgical procedure in order to dishonestly obtain millions of dollars from Medicare and the Federal Employees Health Benefit Program,” said United States Attorney Peace. “Working with our partners at the Department of Health and Human Services Office of the Inspector General and the Office of Personnel Management, we identified the false claims that enabled our Office to negotiate resolutions that resulted in a significant recovery of taxpayer dollars.”

“Medical professionals are expected to bill taxpayer funded health care programs correctly to ensure that they remain solvent and available to those that need their services,” stated HHS-OIG Special Agent-in-Charge Lampert. “Along with our law enforcement partners, this settlement affirms our commitment to ensuring that individuals and entities that bill federal health care programs do so in an honest manner.”

“Today’s settlement reminds all providers that if they submit false claims, they will be held accountable,” stated OPM Deputy Inspector General Vint.        

The defendants treated patients with electro-acupuncture devices called P-Stim and NeuroStim/NSS (“NSS”). P-Stim and NSS procedures transmit electrical pulses through needles placed just under the skin on a patient’s ear. Both treatments are considered acupuncture under Medicare and Federal Employees Health Benefit Program (“FEHBP”) guidelines and are therefore ineligible for reimbursement by the government. From January 2012 through April 2017, the IPMC surgery centers and medical offices submitted claims to Medicare and FEHBP for P-Stim and NSS treatment and associated administration of anesthesia. In submitting the claims, the defendants used a billing code that mischaracterized the acupuncture treatment as a surgical implantation of a neurostimulator.

In addition to paying the civil settlement, Dr. Poonia, New Jersey Interventional Pain Management Center, PC; Advanced Interventional Pain Management Center, LLC; Global Anesthesia Group, LLC; Springfield Surgery Center, LLC; Park Avenue Surgery Center, LLC; and Endo Surgi Center of Old Bridge, LLC, have agreed to enter into an Integrity Agreement with the HHS-OIG. The Integrity Agreement requires that these entities and their owners implement specific measures intended to prevent future health care fraud and address evolving compliance risks. These measures include training for staff on applicable health care fraud laws and submitting to a claims review conducted by an Independent Review Organization to ensure compliance with Medicare billing requirements.

The allegations were brought to the government’s attention through the filing of a complaint captioned United States ex rel. Anu Doddapaneni and Christian Reyes v. Amit Poonia, MD., New Jersey Interventional Pain Management Center, P.C. et al., 18-CV-5214 pursuant to the qui tam provisions of the False Claims Act. Under the Act, private citizens can bring suit on behalf of the United States and share in any recovery. The claims resolved by the settlement are allegations only; there has been no determination of liability, nor a concession by the United States that its claims are not well founded.

The government’s case was handled by Assistant U.S. Attorney Jolie Apicella of the Office’s Civil Division with assistance from Civil Investigator Joseph Giambalvo.

The Defendants:

1. Dr. Amit Poonia, M.D.
2. New Jersey Interventional Pain Management Center P.C.
3. Advanced Interventional Pain Management Center LLC
4. Global Anesthesia Group LLC
5. Park Avenue Surgery Center LLC
6. Springfield Surgery Center LLC
7. Endo Surgi Center of Old Bridge LLC
8. E.D.N.Y. Docket No. 18-CV-5214 (ENV)

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A federal grand jury in Newark, New Jersey, returned a superseding indictment today charging a Florida owner of multiple telemedicine companies with orchestrating a health care fraud and illegal kickback scheme that involved the submission of over $784 million in false and fraudulent claims to Medicare. This is one of the largest Medicare fraud schemes ever charged by the Justice Department. The superseding indictment also charges the defendant with concealing and disguising the proceeds of the scheme in order to avoid paying income taxes.

Creaghan Harry, 53, of Highland Beach, Florida, is charged in the superseding indictment with one count of conspiracy to commit health care fraud and wire fraud, and four counts of income tax evasion. Harry previously was charged in an indictment along with co-conspirators Lester Stockett and Elliot Loewenstern with one count of conspiracy to defraud the United States and to pay and receive kickbacks, four counts of receipt of kickbacks, and one count of conspiracy to commit money laundering. Stockett and Loewenstern previously pleaded guilty. If convicted, Harry faces a maximum penalty of 20 years’ imprisonment for the conspiracy to commit health care fraud and wire fraud, five years’ imprisonment on each count of tax evasion, five years’ imprisonment for the conspiracy to defraud the United States and pay and receive kickbacks, 10 years’ imprisonment for each count of receipt of kickbacks, and 20 years’ imprisonment on the conspiracy to commit money laundering. A federal district court judge will determine any sentence after considering the U.S. Sentencing Guidelines and other statutory factors.

According to allegations in the superseding indictment, Harry and his co-conspirators solicited illegal kickbacks and bribes from durable medical equipment (DME) suppliers and marketers in exchange for orders for DME braces and medications. Harry’s telemedicine companies then allegedly paid physicians to write medically unnecessary orders for these braces and medications. Harry’s telemedicine companies provided orders to DME suppliers that fraudulently billed Medicare over $784 million. Medicare ended up paying over $247 million.

In order to conceal and disguise the health care fraud and illegal kickback scheme, the superseding indictment alleges, Harry directed DME suppliers and marketers not to directly pay his telemedicine companies and instead to pay shell companies that had been opened in the names of straw owners in the United States and foreign countries, such as the Dominican Republic. Harry then transferred the funds from the shell companies to his telemedicine companies in order to pay physicians to write the unnecessary orders.

The superseding indictment alleges that Harry falsely claimed to prospective investors, lawyers and others that his telemedicine companies had not received any kickbacks. Harry instead falsely represented that the telemedicine companies had been receiving revenue of “about $10 million per year” from fees paid by patients to receive telemedicine services, when in fact the revenue of the telemedicine companies was derived from illegal kickbacks and bribes.

The superseding indictment further alleges that Harry committed income tax evasion in the calendar years between 2015 and 2018 by receiving the proceeds of the illegal scheme in the accounts of shell companies belonging to nominee owners and using those proceeds to live a lavish lifestyle. Harry did not file an income tax return or pay taxes on this income.

Assistant Attorney General Kenneth A. Polite of the Justice Department’s Criminal Division; Acting U.S. Attorney Rachael A. Honig for the District of New Jersey; Special Agent in Charge George M. Crouch of the FBI’s Newark Field Office; Special Agent in Charge Scott J. Lampert of the U.S. Department of Health and Human Services Office of Inspector General (HHS-OIG); and Special Agent in Charge Michael Montanez of IRS-Criminal Investigations, Newark, made the announcement.

HHS-OIG, the FBI and IRS-Criminal Investigations are investigating the case.

Assistant Chief Jacob Foster of the Criminal Division’s Fraud Section’s National Rapid Response Strike Force and Trial Attorney Darren Halverson of the Newark Strike Force are prosecuting the case.

The Fraud Section leads the Health Care Fraud Strike Force. Since its inception in March 2007, the Health Care Fraud Strike Force, which maintains 15 strike forces operating in 24 federal districts, has charged more than 4,600 defendants who have collectively billed federal health care programs and private insurers for approximately $23 billion. In addition, the HHS Centers for Medicare and Medicaid Services, working in conjunction with the HHS-OIG, are taking steps to increase accountability and decrease the presence of fraudulent providers.

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WASHINGTON – Ten Florida residents were charged in an indictment unsealed today in the Southern District of Florida for their alleged roles in a $67 million health care fraud, wire fraud, kickback, and money laundering scheme involving the submission of false and fraudulent claims to Medicare for medically unnecessary genetic tests and durable medical equipment.

Daniel M. Carver, 35, of Coral Springs; Thomas Dougherty, 39, of Royal Palm Beach; and John Paul Gosney Jr., 39, of Parkland, the owners and managers of independent clinical laboratories and marketing companies, were each charged with conspiracy to commit health care fraud, health care fraud, conspiracy to pay and receive health care kickbacks and bribes, paying and receiving kickbacks and bribes, conspiracy to commit money laundering, and money laundering offenses.

Galina Rozenberg, 39, and Michael Rozenberg, 58, both of Hollywood, were arrested on Feb. 6, attempting to board a flight to Moscow. Each were charged with one count of conspiracy to commit health care fraud, health care fraud, and conspiracy to commit money laundering. Galina Rozenberg was also charged with additional money laundering offenses.

Louis Carver, 30, of Delray Beach; Timothy Richardson, 29, of Lantana; Ethan Macier, 22, of Coral Springs; and Jose Goyos, 35, of West Palm Beach were each charged with conspiracy to commit health care fraud, health care fraud, conspiracy to commit money laundering, and money laundering offenses. Ashley Cigarroa, 29, of North Lauderdale was charged with one count of conspiracy to commit health care fraud and committing health care fraud.

The indictment alleges that, between January 2020 and July 2021, the defendants referred Medicare beneficiaries for medically unnecessary genetic tests and durable medical equipment. In exchange for doctors’ orders for such tests and equipment, the defendants allegedly paid kickbacks and bribes to telemedicine companies. The indictment further alleges that the defendants falsified Medicare enrollment forms to conceal the true owners and managers of certain laboratories, and submitted false and fraudulent claims to Medicare.

The defendants are anticipated to make their initial appearances in federal court beginning the week of Feb. 28. Federal charges for conspiracy to commit health care fraud and wire fraud, conspiracy to commit money laundering, and money laundering are each punishable by a maximum penalty of 20 years in prison. Health care fraud and anti-kickback violations are each punishable by a maximum penalty of 10 years in prison. Conspiracy to pay and receive kickbacks is punishable by a maximum penalty of five years in prison. A federal district court judge will determine any sentence after considering the U.S. Sentencing Guidelines and other statutory factors.

Assistant Attorney General Kenneth A. Polite Jr. of the Justice Department’s Criminal Division; Assistant Director Luis Quesada of the FBI’s Criminal Investigative Division; Special Agent in Charge George L. Piro of the FBI’s Miami Field Office; and Special Agent in Charge Omar Pérez Aybar of the U.S. Department of Health and Human Services Office of the Inspector General (HHS-OIG) made the announcement.

The HHS-OIG Miami Region and FBI’s Miami Field Office investigated the case.

Trial Attorneys Patrick J. Queenan and Reginal Cuyler Jr. of the Criminal Division’s Fraud Section are prosecuting the case. Assistant U.S. Attorney Sara Michele Klco of the Southern District of Florida is handling asset forfeiture matters.

The Fraud Section leads the Health Care Fraud Strike Force. Since its inception in March 2007, the Health Care Fraud Strike Force, which maintains 15 strike forces operating in 24 federal districts, has charged more than 4,600 defendants who have collectively billed federal health care programs and private insurers for approximately $23 billion. In addition, the HHS Centers for Medicare and Medicaid Services, working in conjunction with the HHS-OIG, are taking steps to increase accountability and decrease the presence of fraudulent providers.

Any doctors or medical professionals who have been involved with alleged fraudulent telemedicine or genetic testing marketing schemes should call to report this conduct to the FBI hotline at 1-800-CALL-FBI.

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Ten people, including two medical doctors, have been indicted in a $300 million healthcare fraud, announced U.S. Attorney for the Northern District of Texas Chad E. Meacham.

The defendants – who stand accused of accused of conspiracy to commit healthcare fraud, conspiracy to pay and receive healthcare kickbacks, offering or paying illegal kickbacks, and soliciting or receiving illegal kickbacks – were charged in a 26-count indictment filed Wednesday afternoon.

“Anti-kickback laws are designed to ensure that financial considerations do not cloud physicians’ judgement,” said U.S. Attorney Chad Meacham. “The Justice Department is determined to prosecute those flouting our nation’s healthcare fraud laws. Patients – and taxpayers – deserve rigorous enforcement.”

“Illegal kickback schemes corrupt the healthcare system. They cause billions of dollars in losses each year, generate business for dishonest service providers and erode trust in our health care system,” said Dallas FBI Special Agent in Charge Matthew DeSarno. “The FBI will continue to work with our law enforcement partners to expose fraud and protect the public from illegal schemes.”

According to the indictment, the founders of several lab companies, including Unified Laboratory Services, Spectrum Diagnostic Laboratory, and Reliable Labs LLC, allegedly paid kickbacks to induce medical professionals to order medically unnecessary lab tests, which they then billed to Medicare and other federal healthcare programs.

The medical professionals -- including internal medicine specialist Eduardo Canova, family medicine practitioner Jose Maldonado, and nurse practitioner Keith Wichinski – allegedly accepted the bribes and ordered millions of dollars’ worth of tests.

Meanwhile, Unified, Spectrum, and Reliable disguised the kickbacks as legitimate business transactions, including as medical advisor agreement payments, salary offsets, lease payments, and marketing commissions.

The labs, through marketers, allegedly paid doctors hundreds of thousands of dollars for “advisory services” which were never performed in return for lab test referrals. They also allegedly paid portions of the doctors’ staff’s salaries and a portion of their office leases, contingent on the number of lab tests they referred each month. In some instances, lab marketers even made direct payments to the provider’s spouse. (When the labs threatened one provider that payments would cease if he didn’t refer more tests, he immediately increased his lab referrals, averaging approximately 20 to 30 referrals per day.)

Knowing they could disguise additional kickbacks using a provider-ownership model, the founder of Spectrum and Unified, Jeffrey Madison, convinced the co-founders of Reliable, Biby Kurian and Abraham Phillips, to convert Reliable into a physician-owned lab. Reliable offered physicians ownership opportunities only if those physicians referred an adequate number of lab tests. In some cases, they made advance disbursement payment to physicians in an effort to appease the physician and ensure he would not send samples to other labs.

As a result of these kickbacks, laboratories controlled by the defendants were able to submit more than $300 million in billing to federal government healthcare programs. Between 2015 and 2018, Dr. Maldonado alone received more than $400,000 in kickbacks for ordering more than $4 million worth of lab tests and Dr. Canova received more than $300,000 in kickbacks for ordering more than $12 million worth of lab tests.

Defendants indicted are:

• Jeffrey Paul Madison, 56, founder of Unified Laboratory Services and Spectrum Diagnostic Laboratory
• Mark Christopher Boggess, 49, chief operating officer for Spectrum and Unified
• Biby Ancy Kurian, 49, co-founder of Reliable Labs, LLC
• Abraham Phillips, 50, co-founder of Reliable Labs, LLC
• Keith Allen Wichinski, 50, board-certified nurse practitioner based in San Antonio
• David Michael Lizcano, 56, ]owner of DCLH, a marketing firm engaged by Unified, Spectrum, and Reliable
• Laura Ortiz, 58, sister of David Lizcano and employee at his marketing firm
• Juan David Rojas, 34, owner of Rojas & Associates, another marketing firm engaged by Unified, Spectrum, and Reliable

An indictment is merely an allegation of criminal conduct, not evidence. Defendants are presumed innocent until proven guilty in a court of law.

If convicted, the defendants face up to 55 years or more in federal prison.

The Federal Bureau of Investigation’s Dallas Field Office, the U.S. Department of Health and Human Services’ Office of Investigations, the Defense Criminal Investigative Service, and the Veterans Affairs’ Office of Inspector General conducted the investigation. Assistant U.S. Attorney P.J. Meitl is prosecuting the case.

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To save money and keep patients, VA administrators are overruling decisions by VA doctors and their patients, in some cases cutting off care.

When Christine Russell read the message from the San Diego VA announcing it would no longer pay for her cancer treatment, all the pain came rushing back.

For nearly three years, the federally funded Veterans health care system had misdiagnosed her breast cancer as mental illness, she and her team of advocates contend. After discovering the cancer in late 2018 — when the tumors had already spread — the VA agreed to pay for the former Navy Reserve lieutenant to get her medical care from other doctors in the San Diego area.

Russell filed four federal complaints in early February this year about her ongoing challenges accessing health care, medication and caregiver services through the VA. Days later, a group of San Diego VA administrators mailed her a letter that called her “disruptive” and announced they would no longer fund her appointments outside the VA because her health care was too “fragmented.”

Russell was $30,000 in debt from medical expenses since developing cancer. She couldn’t afford to see her doctors if the VA didn’t pay for it.

“It was like they cut my legs off,” Russell said. “They cut off my lifelines, because all those doctors are my integrative support team. They are why I’m still alive.”

An inewsource investigation in partnership with USA TODAY has found that like Russell, Veterans across the country are caught in the crossfire of the VA’s battle to retain patients and funding since the passage of a landmark health care law known as the Mission Act.

When Congress and then-President Donald Trump passed the bipartisan law in 2018, they said it would ensure American citizens who fight to protect the U.S. can access high quality medical care after leaving the military. When the Department of Veterans Affairs can’t deliver that care for any of six reasons, it’s supposed to pay other health care systems to do it instead.

A review of thousands of pages of department manuals and medical records, along with interviews with dozens of patients, advocates and providers, shows that VA administrators are overruling doctors’ judgments and preventing them from sending their patients outside the VA health care system.

This bureaucratic process has ramped up over the past two years as part of an effort to save money and retain patients within the VA, records show.

“That’s tragic and jarring,” said Ryan Gallucci, a national director for Veterans of Foreign Wars, after learning what the VA’s manuals show.

“I think it warrants an organization like ours asking more pointed questions and ensuring the VA is upholding the intent of the Mission Act,” he added.

More than 9 million Veterans are enrolled in the VA, the nation’s largest health care system, which is composed of more than 170 medical centers and 1,000 outpatient offices.

The U.S. is facing urgent demands from Veterans for medical and mental health care. Veterans have faced almost 20 million cancelled or delayed health care appointments during the COVID-19 pandemic, and the U.S. withdrawal from Afghanistan in August has caused crisis hotline calls to spike as former service members have struggled to process the unfolding events.

Dozens of Veterans and caregivers throughout Southern California described their struggles to access health care outside the VA since the Mission Act was passed: A partially blind skin cancer survivor was told to take a dangerous trip to the VA when a new lesion developed, instead of visiting his neighborhood dermatologist. A Veteran with a seizure condition has waited years for a course of treatment outside the VA. Suicidal patients were cut off from what they considered “life-saving” mental health treatments by employees overwhelmed with paperwork — against the advice of the VA’s own psychiatrists.

In interviews, service groups and congresspeople from both political parties said Veterans should be offered the best health care available, and money should not affect the quality of care they receive.

“We just spent trillions of dollars prosecuting this 20-year war in Afghanistan, and by comparison we’re arguing nickels and dimes in caring for the Veterans who prosecuted those wars,” Gallucci said.

The Mission Act has had financial consequences for the VA. Since the law was enacted, more Veterans have left for other health care systems than the VA anticipated, forcing the government agency to shell out billions of dollars for private care. If the trend continues, the VA’s own hospitals could end up with smaller budgets to spend on their services and staff.

In late 2019, the VA began the “referral coordination initiative” to return Veterans to its hospitals. An internal department manual shows the changes are supposed to help the VA make “good financial decisions” and “maintain funding of specialty care” in the future.

Like the VA, private health care systems have financial incentives to retain patients and cut costs. The difference, experts said, is that Veterans represent a unique and vulnerable population that the government has pledged to care for.

“If they have a problem with the budget, they need to come and talk to Congress,” said Rep. Mike Bost, R-Ill., ranking member of the House Committee on Veterans’ Affairs. “They don’t need to go ahead and try to figure out how to take services away from our Veterans.”

Under department policy, VA doctors usually don’t send their patients outside the health care system on their own, records show. They can make recommendations that go through reviews by other staff — such as administrators, clerical workers or clinicians trained by hospital leadership — who can cancel treatment requests and insist patients come to the VA instead.

Following the VA’s new initiative, department hospitals have also set up select teams of health care personnel who can review medical records and use algorithms to decide if patients qualify for care outside the VA before interacting with those patients.

And for Veterans ultimately approved for treatments elsewhere, the VA can require checkups at its hospitals anyway — that includes Veterans facing severe disabilities, burdensome drives or long wait times for VA appointments.

“It basically defeats the whole purpose of the Mission Act,” said Darin Selnick, senior advisor to Concerned Veterans for America, an organization pushing for Veterans to have more access to private health care.

“We need to be Veteran centric,” he added. “It's about what the patient needs, not what the VA needs.”

Selnick helped write the Mission Act, working in the Trump administration and the VA as a health care policy expert to implement the law until July 2020. He read excerpts of the department manuals obtained by inewsource.

“If I was still at the VA and someone showed me this in July, I would have ripped it to shreds and I would have said there’s no way in Hell you’re going to use this stuff,” Selnick said.

The VA received its largest-ever budget this year — an amount that has doubled over the past decade. A national spokesperson said the department has “sufficient funds” to send Veterans out for private care.

VA officials said they are following Mission Act requirements, and treatment decisions are based on patients’ medical needs. They added that the review process is supposed to ensure Veterans can always get their care at the VA if they want to.

Hospital doctors and managers at the VA said they believe they can deliver the most effective care internally, because they offer high-quality services and can more easily coordinate treatments and paperwork.

Dr. Kathleen Kim, the San Diego VA chief of staff, said physicians sometimes incorrectly try to relocate patients for treatments her hospital can offer, and administrators are “regularly educating” them to help keep Veterans at the VA.

“Because of the nature of the Mission Act, the VA is sending a lot of care in the community, and frankly we're worried that we're not going to be able to pay our bills,” Kim said.

The VA has approved over 12 million referrals for outsourced care since the Mission Act was implemented, including 5 million in the most recent 12-month period, according to data the department supplied. inewsource, through a series of records requests and direct inquiries, attempted to determine how many doctors’ requests for outsourced care have been denied by the VA, but the data provided was incomplete.

An August inspector general report highlights the personal impact the VA’s administrative decisions can have. When the San Diego VA stopped paying for ketamine treatments at a private clinic, 28 mentally ill patients experienced unnecessary distress, the report found. Inspectors pointed out the drug’s unique properties for combating severe depression.

Shortly after learning the VA wouldn’t fund her treatments, a former Marine Corps pilot took her life.

“They need to do right by these Veterans,” said Rainelle Wolfe, a full-time caregiver for her husband Kiowa, another Veteran who was cut off from the private ketamine treatments over a year ago.

The San Diego VA has started offering a low-dose version of the drug that many Veterans have not found therapeutic, including Kiowa Wolfe.

Now, the Marine Corps Veteran spends most of his time lingering in bed, reliving trauma from the Afghanistan War.

“We’re not political,” he said. “It’s not in our nature to be political. But keep politics and all this BS out of Veterans’ health.”

Part I: A body on fire

Long before anyone realized she had cancer, Christine Russell walked slowly and painfully to the car waiting for her outside the San Diego VA emergency room. Her body hurt so much she could barely move.

The Lyft driver came out to assist her, then approached a nurse at the hospital entrance to ask if Russell would need any special care during her transport home. As the driver would later retell in a court filing, the nurse assured him the answer was no. The 39-year-old Navy Veteran was “crazy” and imagining her symptoms.

It was mid-2018, almost two years since Russell first felt the unbearable pain in her body. It had become too difficult to drive or take care of herself, so she started paying thousands of dollars out-of-pocket for caregivers to look after her.

In her medical chart from late 2016, Russell’s VA physician wrote that she “displays abnormal anxiety about her health, especially with an unwarranted fear of having a serious disease.”

Russell said doctors told her she had post-traumatic stress disorder and refused to run tests until she tried psychotropic medications. Without a clear explanation for her escalating symptoms, Russell rushed to the emergency room more than a dozen times.

Finally, in the summer of 2018, her new primary care doctor agreed to order a scan of her chest. A radiologist noticed something unusual and asked for more tests.

The diagnosis: stage IV breast cancer.

Her case was complex. Russell suffers from severe allergies and sensitivities, which she believes came from her exposure to hazardous chemicals on a counter bioterrorism mission in the Middle East. Perfumes, highly processed foods and a long list of medications can aggravate her symptoms.

The VA’s course of cancer treatment, chemotherapy pills, was excruciating.

“It felt like my whole body was burning and on fire,” Russell said.

The Veteran was also experiencing hormone imbalances and pelvis pain, which needed tailored treatments that wouldn’t cause their own unbearable side effects. Russell thought she would be better off getting care from specialists elsewhere — doctors she could trust who could better address her complicated symptoms.

Over the next three years, the VA approved a slew of requests for Russell to see at least eight specialists outside the department.

Her symptoms slowly improved. But traveling to her appointments was impossible without the help of an at-home caregiver. The VA tried to provide her with aides, but they didn’t follow the protocols Russell required for her sensitive immune system.

Russell hasn’t been able to get a new caregiver since November 2020, the same month she was supposed to begin radiation therapy. With no aide to assist her, the Veteran never got the treatment.

Months of correspondence with VA employees didn’t resolve the issue. In February, Russell filed complaints with the VA’s inspector general and the White House.

That’s when she lost it all.

In a three-page letter, VA administrators told Russell they would no longer pay for her health care outside the department and insisted she follow the “code of conduct” moving forward. They said she had engaged in “disruptive behavior” by intimidating social work staff with angry voicemails, using profanity and telling them they should be fired for not doing their jobs.

“The multidisciplinary team reviewed your current status and confirmed that your health care is fragmented due to a disproportionate amount of care received in the community,” the letter states.

The administrators said this care was “no longer reasonable or necessary” and would be “limited to services that cannot be provided in a timely manner or are unavailable” at the San Diego VA, “as required by” national policy.

The letter was signed on Feb. 19 by the director of the Veterans Experience Office, the section chief of primary care and the chair of the Disruptive Behavior Committee.

Russell was not consulted about her health care needs before the letter was sent.

“It was a nightmare,” Russell said, adding, “They really didn’t know me or what I had gone through or why I was even still alive.”

She described her reaction as a “heavy mental breakdown” as she struggled with thoughts of suicide and almost checked herself into a hospital for psychiatric care.

But she chose to argue her case instead.

Russell had done it before. When enrolled in the Navy, she filed a complaint about entry fees for military parties, which led officials to relieve her of her duties, escorting her out of Kuwait by military police. She then filed a whistleblower retaliation case, which was substantiated a year later by the Pentagon inspector general’s office.

“I’m always about integrity,” Russell said. “And if I see something that’s not ethical going on or if I see an error, because of what I’ve been through, I’m going to question that error.”

Part II: A Veteran’s best interest

Armed with a copy of the Mission Act and her long clinical history, Russell told the San Diego VA that it was in her best interest to continue her medical treatments elsewhere.

The federal health care system will pay for Veterans to get medical care from other doctors if the patients meet any of six criteria, including long drives or wait times for VA appointments.

The most contentious — and some argue, most critical — reason to send Veterans outside the VA is when it’s in their “best medical interest.” That decision should be made by the Veteran and their “referring clinician,” the law says, and can help address a patient’s unique needs.

For instance, a dermatologist might not specialize in a patient’s skin condition, or a Veteran suffering from military trauma could be triggered by trips to the VA. In these kinds of cases, if it would improve a patient’s health, a doctor could send them to another medical provider.

“Every patient experiences things differently,” Russell said. “And if they’re not getting all their needs met, then it is in their best medical interest to go somewhere else to have all their needs met.”

Russell told the VA that stopping her current treatments would exacerbate her cancer symptoms — and it would put her health care back in the hands of a hospital that didn’t have the expertise for her conditions.

Her VA primary care doctor requested she return to her medical team outside the hospital, the Veteran said, but warned the request probably wouldn’t be approved.

At the San Diego VA, these kinds of treatment requests are usually reviewed by “delegated authorities” who can deny them if they think the hospital’s own doctors can deliver the care.

Kim, the hospital’s chief of staff, said these designated physicians go through regular training, so they understand all the services the VA offers and can make more informed decisions than other doctors.

“Some of it, in my mind, is just a lack of knowledge about what the services are,” Kim said.

San Diego County is home to roughly a quarter million Veterans, the fifth-highest of any county in the nation. Its local VA health care system, which also covers the neighboring Imperial County, serves about 85,000 patients.

Kim, who oversees Veterans health care across the region, said it’s often best for patients to come to the VA, even if that’s not what their doctors want.

“The reality is that does not trump the fact that the service can be provided at the VA within a timely fashion,” Kim added.

For a complicated case, Kim and leaders at other VA hospitals can personally review medical records and decide what’s in a patient's best interest, documents show.

The VA’s many hospitals can rely on different procedures, but nationwide, employees are instructed to follow handbooks. VA spokespeople were hesitant about providing them, saying they were intended for internal use.

Over the past two years, the VA has started putting treatment requests in the hands of “referral coordination teams” made up of registered nurses and other personnel, according to the manuals. A team member is supposed to spend 10 to 25 minutes reviewing a patient’s medical charts and deciding if they qualify for care outside the VA. They can also forward requests to designated physicians for approval.

The initiative “shifts the referral responsibility” so most doctors aren’t choosing to relocate their patients themselves, the documents show, which will “decrease inconsistent and inappropriate” treatment plans.

Hospital leaders are told to monitor health care costs as a “key performance indicator” of success.

“That is not what the Mission Act says,” said Rep. Bost of Illinois about the review process.

“I understand my health care and my doctor understands my health care,” he added. “Between the two of us, we make the decision, not some (team) that’s put in place by some government agency, nor should it be.”

The National VA pointed to federal regulations stating it can conduct reviews of doctors’ decisions so long as they focus on health outcomes. Spokespeople also said that VA doctors still have the power to send their patients outside their hospitals.

To do that, doctors have to use a specific software program that offers a pre-established list of justifications — otherwise it’s not considered a “true” medical decision, according to department manuals.

Once Veterans are approved for care outside the VA, staff are supposed to call them and try persuading them to come to the VA anyway.

Employees are told to follow scripted language that outlines the benefits of staying at its hospitals and the burdens of leaving them. The scripts tell Veterans they will be responsible for transferring their own medical records if they choose a different provider.

“If you wanted to stay in the VA, you always can stay in the VA, but once you’ve made a decision to go to community care, you’ve decided for whatever reason it’s best for you not to,” said Selnick, who helped write the Mission Act

“Doing extra hoops to keep you in the system is counterproductive.”

When the VA stopped authorizing her treatments, Russell was left with two bad choices: pay out-of-pocket or stop seeing the doctors that had helped her through a complex cancer. She chose the expensive option.

With her credit cards maxed out, the Veteran began an online fundraiser for the accumulating bills and turned to her church community for food deliveries.

The cancer has worn on her. Russell, now 44 years old, wakes up disoriented and forgets where she is. It takes her hours to clamber out of bed, and she inches forward around her house with the aid of a cane.

When she manages to leave her home, Russell adorns her outfits with American flags and, with a smile, tells anyone who will listen that she is proud to be an American. She still remembers the enthusiasm she felt 25 years ago as a teenager in Barstow, California, enrolling in the Naval Academy.

Through months of heated conversations, Russell was able to reestablish most of her old doctors.

But maintaining her care outside the VA is an ongoing problem. In August, Russell received a voicemail from her VA primary care doctor’s office. The physician had requested more appointments with specialists outside the hospital, and the requests were denied.

Russell is still searching for solutions.

Part III: Living with demons

The mental health crisis among America’s Veterans can be told through a bleak series of statistics.

One in five Veterans who served in Iraq and Afghanistan suffers from depression or PTSD, and more than half of Veterans who need mental health treatments don’t receive them. About 17 former service members take their lives every day — double the rate of the general public — and the vast majority of Veterans who died by suicide never sought services from the VA health care system.

Recognizing the troubling trend, the government has boosted its focus on mental health in the past few years. The VA has expanded its resources for suicide prevention, and Congress has put forward numerous bills to help address the issue.

But the VA can’t always provide the mental health support Veterans need. Under the Mission Act, Veterans have the same treatment rights for physical and mental health issues. If a patient isn’t benefiting from the VA’s services, their doctor can try to send them somewhere else.

That doctor, however, might not have the final say.

A Veteran's fight for mental health treatment

At the San Diego VA, administrative staff dismissed the warnings of psychiatrists and denied community mental health treatments to suicidal patients, records show. Soon after learning the treatments had been discontinued, one of the Veterans died by suicide.

Over two and a half years, the San Diego VA sent more than 60 Veterans to a private clinic to try the drug ketamine, a therapy for people with severe, treatment-resistant depression. Many of the patients showed remarkable improvements, and VA psychiatrists continued sending them back for sessions.

One of them was Kiowa Wolfe, a 38-year-old Afghanistan War Veteran who was medically retired in 2018.

Nine years ago, Wolfe was defending a dam on a mountaintop in the Helmand Province when he took enemy fire. In the commotion, he stood up to get his bearings, and his 6’5” frame was instantly visible. Bullets flew in his direction and sent him tumbling down the side of the mountain.

The Marine returned from war with traumatic brain injury and wounds along his right side that demanded multiple surgeries. But his mental anguish hurt just as much. Intrusive memories of the battle overwhelmed him, and some days he felt he no longer wanted to live.

The VA classified him as 100% disabled, mostly due to his post-traumatic stress.

The government tried more than a dozen treatments, including a variety of medications and therapists. Nothing made a difference. Finally, Wolfe’s psychiatrist recommended ketamine. The VA didn’t offer it, so it paid for him to go to Kadima Neuropsychiatry Institute, a private clinic down the street.

Wolfe felt relief for the first time in years. He managed to walk into a movie theater and take his children to a Blink-182 concert — the kinds of activities he had once avoided at all costs.

“It cut down on the hyper-vigilance, where I’m not just freaking out and my head’s on a swivel everywhere, and I have to check out everybody and everything,” Wolfe said. “I could just actually relax and put my arm around my son and talk to him and act like a human.”

The drug’s effect typically lasts a few days. With the VA’s support, Wolfe returned for treatments twice a week, his wife always by his side.

That changed in October 2019, when a note appeared in Wolfe’s medical record from the VA Office of Community Care, which helps Veterans arrange external medical appointments.

Dr. Susan Trompeter, the former chief of the San Diego office, issued a directive about the mentally ill patients on ketamine therapy. She called the drug “experimental,” said the VA could no longer pay for it and told the hospital’s psychiatrists not to submit any more treatment requests.

Trompeter, whose research focus is women’s reproductive health, did not respond to interview requests.

The VA Chief of Psychiatry pushed back, arguing the hospital could not “precipitously stop these treatments” for patients with severe depression. But the decision had been made, and he relayed the message to mental health staff.

“So please do not discuss/offer this as a possibility to patients until further notice from me,” Dr. Brian Martis wrote in an email. He told them not to “make verbal comments to patients or written comments … expressing your frustration” about the change.

Medical records and emails show VA doctors feared the sudden decision could be dangerous for their unstable patients. One Veteran with a history of suicide attempts was a particular concern.

“We need to ensure he does not have a break in treatment,” one VA doctor wrote in his medical chart. Another warned of the “potential acuity of the situation” and said nobody had followed up with the Veteran.

“I am concerned as this is a HIGH RISK pt,” the doctor added.

Under the Mission Act, patients are allowed to continue treatments outside the VA if they have ongoing sessions, because cutting them off can have negative consequences.

Kadima’s founder, Dr. David Feifel, decided Veterans could keep their upcoming appointments even if the VA wouldn’t pay for them. He did it, he said, because he feared what would happen otherwise.

“Something’s out there that can help you, and now they’re taking it away,” Feifel said. “To have it and then not be allowed to have it makes living with those issues and demons even more difficult.”

After she learned the VA would no longer pay for her ketamine therapy, Navy and Marine Corps Veteran Jodi Maroney died by suicide. inewsource first reported the death last year, prompting an investigation by the VA inspector general’s office.

In an August report, inspectors found the San Diego VA’s denial of care was a “contributory stressor” leading up to her death. But the circumstances were “multifactorial” and “complex,” the report said, and they couldn’t conclude the VA was responsible.

Hospital staff said they faced a “large volume” of referrals when the Mission Act went into effect in mid-2019, according to the report. The health care system needed to sign a new contract to pay for ketamine therapy, but the situation “was overlooked” until the VA missed its deadline.

For three weeks, the VA had no way to pay for ketamine therapy and didn’t explain to Veterans why they couldn’t get their treatments. When Maroney died, the hospital quickly signed off on more sessions.

That lasted about five months. Starting in March 2020, the VA stopped paying for Veterans to get ketamine therapy, even though the hospital’s psychiatrists had requested additional treatments.

For Wolfe, the VA’s decision was tantamount to betrayal.

“It feels like I’m getting stabbed in the back with a bowie knife and getting it twisted,” Wolfe said.

“If I was held to such high standards in the Marine Corps, why are these people getting away with so much with mistreating Veterans?” he added.

Patients pleaded with hospital officials, describing how the drug had saved their lives, and shared suicidal thoughts and dreams with the private ketamine clinic.

Feifel sent frantic messages to VA psychiatrists and administrators, warning of a possible second death if the hospital didn’t act quickly.

“We were under the impression that the VA learned from its mistake and under no circumstance would it follow the same catastrophic path that resulted in that tragic outcome,” Feifel wrote. “And yet, here we are, watching a train wreck in slow motion… AGAIN!”

The VA never replied.

In an interview and emails, San Diego VA administrators have made multiple inaccurate statements about their ketamine program and health care services.

The hospital has repeatedly stated that community care staff don’t make clinical judgments and can’t overrule doctors — they process paperwork and help Veterans set up appointments outside the VA.

Later, national VA spokespeople clarified that these employees do have the ability to review referrals, ask questions about patients’ clinical needs and cancel requests if they “cannot verify the eligibility” of the Veterans.

In VA manuals, community care staff are also instructed to “consider funding availability” when offering treatment options to patients.

In mid-October, the VA announced it will be phasing out community care offices over the next year and restructuring their responsibilities in order to “operate as a high-reliability, Veteran-centric organization.” The VA has not explained if the transition will change how staff process treatment requests.

According to the inspector general report, San Diego’s community care employees chose to cut patients off from ketamine therapy the second time because of “administrative factors,” like outdated forms and misplaced paperwork.

The employees had “resistance to clinical input from mental health leaders” and caused serious distress to mentally ill patients, the report states.

Following the inspection, the San Diego VA hired more administrative staff and assured investigators they would base their decisions on Veterans’ medical needs.

Those needs, as Wolfe would later find out, are up for interpretation.

Part IV: Circling the drain

Wolfe laid in bed, crippled by the memories that had resurfaced since the U.S. withdrew its last troops from Afghanistan.

All he wanted was a moment of relief. But the one treatment he knew would help was the one the VA wouldn’t pay for.

At $300 per visit, Wolfe can’t afford to pay out-of-pocket for regular ketamine therapy. Private donors have funded some sessions, and in times of crisis, the Veteran has shelled out the full cost himself.

Wolfe and his wife Rainelle, who serves as his full-time caregiver, have spent the past year begging the VA to send him back to Kadima for more treatments.

“I do not have the ability to refer Kiowa to Kadima,” Wolfe’s VA psychiatrist wrote in a December message. “I am not involved in any way here at the VA with the implementation or adjudication of any aspect of the Mission Act.”

Medical records show Wolfe’s psychiatrist referred patients to ketamine therapy in 2018 and 2019, before the Mission Act went into effect.

“I know you are both suffering and wish you only health and happiness in the year to come,” the doctor wrote.

The hospital has refused to tell the Wolfe family who has the power to approve his treatment requests. VA doctors have told the Veteran these are “administrative decisions” and they don’t know who’s responsible for making them.

“If you get the answers, call me,” one physician told Wolfe.

San Diego VA spokespeople would not give inewsource the names of the hospital leaders in charge of mental health treatment requests or provide a reason they wouldn’t share the information.

“If they’re not making the decision and not telling you who’s making the decision, how can you even advocate for the Veteran?” said Renee St.Clair, Wolfe’s advocate and former chief operating officer at Kadima.

Veterans have avenues to fight the VA’s health care decisions, but attempting to use them can be a full time job. St.Clair, an attorney, is assisting the family pro bono. She has asked for help from more than a dozen service groups and government officials, including Congressional offices and the VA inspector general.

She also sends weekly emails to VA doctors and administrators asking them to approve Wolfe’s ketamine treatments.

“Kiowa gave so much and is asking so little — a signature on a form which could save his life,” St.Clair wrote in one message.

Veterans can submit clinical appeals to a VA hospital’s patient advocate’s office, which should be reviewed in three days by administrators, and then a second appeal that goes to regional VA leaders.

But Veterans and caregivers who tried contacting patient advocates said staff either didn’t return their calls or didn’t help resolve their issues. The Wolfe family has not gotten responses from the San Diego office, they said.

The VA has never sent Wolfe a written denial of his treatment requests, like its policies describe.

“This is madness,” Rainelle Wolfe said. “I cannot believe that everybody’s acting like their hands are tied and they’re all passing the buck. Nobody wants to stand up and have some integrity and treat Veterans the way they need to be treated.”

Waiting for VA health care

Since the San Diego VA stopped paying for his private sessions in mid-2020, Wolfe has been shuffled through the hospital’s attempts to build its own ketamine program. The ordeal has had disastrous consequences.

Over the course of two months, the VA administered different kinds of the drug at low doses. It didn’t work. Wolfe started backsliding into severe depression. But when the private clinic asked the VA to send him back for more appointments, a registered nurse in the local community care office denied the request.

It was “not clinically appropriate,” she wrote. The VA could provide the treatments he needed.

Then, in October 2020, VA nurses administered ketamine to Wolfe on a gurney in the post-anesthesia care unit. The family recalls that the Veteran’s psychiatrist wasn’t present for the infusions, and he wasn’t allowed to bring his wife or service dog with him.

The experience was traumatic. Wolfe blacked out and entered a fit of rage. He screamed uncontrollably at his wife. When he finally got his bearings, he knew one thing absolutely. He would not come to the VA for another ketamine treatment.

Because of ketamine’s psychedelic properties, the drug’s effects are highly context-dependent. Changing how the drug is administered or delivering it to a patient in an uncomfortable environment could lead to negative outcomes.

Four Veterans said the VA’s program has failed to provide the relief they need.

By personally paying for treatments and obtaining donor funds, St.Clair has helped nine patients return to Kadima for more ketamine sessions. She said at least twelve Veterans have not found the VA’s program therapeutic.

Wolfe’s psychiatrist — considered the San Diego VA’s “local expert” on ketamine — has acknowledged to the Veteran that the hospital’s program is “not the same” as what the private clinic offers.

Despite his towering height, Wolfe speaks softly and slowly, and he leaves most of the talking to his wife and four children. Their home is decorated with military memorabilia, the fridge featuring an old photo of the family patriarch in uniform. Rainelle, who met Wolfe in 2006 when he was 22 years old, has spent much of the past year rousing him out of bed, sometimes unsuccessfully.

“Is it really in his best interest to get all his care at the VA?” Rainelle Wolfe said. “Because he’s slowly circling the drain. He spends the majority of his time in his room in the dark.”

Asked why the VA won’t fund private treatments for Veterans failing out of the hospital’s program, the chief of staff said it was a legal matter.

“The relationship with that clinic has become highly contentious,” Kim said. “And one of the former administrators every Friday sends what I would call a nasty email complaining about this issue. And so at this point, we’ve turned it over to legal counsel.”

In May, the Wolfe family had a brief moment of hope. Congressman Darrell Issa’s office convinced the hospital to take another look at the Veteran’s case.

The VA conducted a “comprehensive review” of his medical needs, according to an email the Congressional office sent the Wolfe family.

The hospital “is confident that it is in your best medical interest to receive your mental health care (there) so that there is a comprehensive and integrated approach to maximize your treatment outcome,” it said.

The review was performed by an unnamed group of VA employees.

Part V: Closer to perfection

The Mission Act was passed in the midst of a fierce political debate over the future of the VA health care system.

The dispute dates back to 2014, when an overwhelmed VA hospital in Phoenix was caught concealing appointment wait times. The scandal prompted new laws and rules that let Veterans access private care more easily.

But navigating health care choices was still a confusing and complex process, and Congress was looking for solutions. Democrats pushed to strengthen the VA with more funding and services, while Republicans wanted to make it easier for Veterans to go to private doctors.

The Mission Act was their compromise. It created a network of approved community providers and expanded the reasons Veterans could visit them. It also funnelled billions of dollars into the VA so the department could cover the expenses.

Now, Veterans can get their primary and mental health care outside the VA if an appointment would take longer than a 20-day wait or 30-minute drive. For specialty care, that extends to a 28-day wait or a 60-minute drive.

“The Mission Act created an environment where all Veterans, no matter where they live, would have access to VA care,” said Rep. Jack Bergman, R-MI, who voted for the law in 2018. “It may not necessarily be at a VA hospital, but at a place close to them where they can actually receive the care in a timely manner.”

But Southern California Veterans said they are still struggling to get appointments with private doctors since the law was passed.

Former service members in rural areas — facing drives of an hour or more for VA visits — said they are routinely told to visit the department’s hospitals to assess whether care is necessary. Veterans facing long wait times said their private care can be cut off after a handful of sessions, and they have to return to VA physicians.

“It’s not working here,” former Army captain Gary Shearer said. “It hasn’t been working for some time.”

Shearer suffers from chronic neck pain and has gone blind in one eye, making each trek to the VA a dangerous burden. He lives in Yucca Valley, almost 50 miles from his VA primary care doctor and 80 miles from the closest Veterans hospital.

Because of the long drives, Shearer qualifies for private doctor’s visits closer to home. But the VA has asked him to return to its own offices for checkups and assessments.

In December, Shearer saw a bump on his forehead that he knew needed medical attention. The Veteran has a 20-year history of skin cancer and had cancerous lesions removed in the past. He wanted the Loma Linda VA to help him schedule an appointment with his neighborhood dermatologist.

The VA said no.

An “approving official” at the hospital reviewed his case, documents show. They decided a VA primary care doctor would have to conduct a skin exam first.

Shearer worried it would take months to go through this circuitous process: schedule an appointment at the VA, endure a long road trip for the visit, convince the doctor to request a dermatology appointment and wait for the VA to approve and schedule the request.

“The longer I waited, the more tissue they were going to have to take,” Shearer said.

The Veteran didn’t want to take any chances, so he went to the dermatologist on his own. Shearer’s lesion was diagnosed as basal cell carcinoma and required an urgent surgery with a price tag of $3,000. It was too steep for him to pay out of pocket, but he was able to use his private insurance plan to cover the cost.

About one-quarter of working-age Veterans — more than 730,000 people — don’t have a second medical payment option like Shearer does. If he didn’t have a backup insurance plan, the Veteran said, he would have to rely on the VA’s medical decisions.

Shearer has a long list of grievances against the federal health care system. The VA cut down his weekly neighborhood chiropractor visits to only 12 sessions per year, despite his severe spinal injury from a military tank accident.

The back pain feels like “someone has taken a ball bat and beat me around the rib cage,” the Veteran wrote in a complaint to the VA.

Shearer said he waited more than 50 days for an answer from the Loma Linda VA about extending his chiropractor appointments. The facility told him it could award up to eight more sessions per year if he agreed to drive all the way to the hospital for a pain assessment.

The former Army captain has sent many letters, ripe with colorful turns of phrase and religious proverbs, to the VA’s patient advocates. They led nowhere.

“The Mission Act, you say,” he wrote in one complaint. “What Mission Act? It is only a dream.”

VA manuals say Veterans can receive an unlimited number of outsourced treatments, but only if reviewers deem them “clinically appropriate.”

Dr. Peter Kaboli, a VA physician in Iowa and health care administration expert, said having the department conduct reviews — and encouraging patients to come to the VA when possible — is better for Veterans and the future of the health care system.

“Is there going to be an incentive to bring care back to the VA?” Kaboli said. “I think so, because I think we do it cheaper in most cases, and we do it as good if not better in most cases.”

Patients described their anguish when they have suddenly faced denials of care and letters demanding they return to Veterans hospitals. Some said they have waited months or years for the VA to set up or renew appointments with private doctors.

Warner Springs resident John Seymour, who lives an hour and a half from the closest VA facility, has waited two years for the VA to arrange a treatment plan for his debilitating illness.

Seymour suffers from a plethora of conditions that are commonplace among America’s Veterans, including PTSD, diabetes and severe spinal injury. He has also developed non-epileptic seizures from psychological distress, which cause uncontrollable spasms and leave him unable to communicate.

A VA neurologist diagnosed Seymour’s seizures about two years ago and recommended he try cognitive behavioral therapy, but the doctor didn’t submit a treatment request.

Over time, Seymour’s symptoms grew more extreme. He collapsed in the bathtub, unable to breathe, and in a similar incident, ended up in the emergency room. He waited months for another neurology appointment, which was cancelled twice.

In March, the Veteran’s VA primary care doctor offered to send in a treatment request, which was routed to the VA Office of Community Care. It’s still pending.

Amy Warix, the Veteran’s wife and full-time caregiver, said the VA has taken so long on the request that staff couldn’t find it in their computer system. Warix had to call her husband’s doctor and have the request resubmitted.

Now, when she asks for updates, Warix gleans little information.

“They can’t say, ‘No, you don’t get the care,’ and they can’t say, ‘Yes, you will get the care,’” she said. “They’ll just say, ‘It is processing.’”

Warix spends hours on the phone with the VA trying to manage incomplete medical requests.

She spent seven months asking the VA to restart visits with a private psychologist when they were suddenly cut off in November — just after her husband had shared thoughts of suicide. She is still waiting for the VA to approve more appointments with a neighborhood dentist to finish urgent work that began in March.

“He’s a patient that needs continuous care,” Warix said. “So I always have a referral that I am chasing down because they haven’t finished processing yet.”

Since the Mission Act launched, the VA decided to handle outsourced health care requests itself — taking over the job from its contractors — so its employees could have direct contact with Veterans about their needs. But the department was critically understaffed and unable to handle the workload, according to federal reports from the Government Accountability Office.

The staffing shortage has impacted Veterans seeking medical care. In mid-2020, patients were waiting an average of three weeks for the VA to process specialty care requests and six weeks until their community appointments. By comparison, referrals from one VA doctor to another took one week.

National spokespeople said Veterans with urgent needs are prioritized, and processing time for non-VA treatments is now under two days.

Lawmakers have sent numerous inquiries to the VA asking why Veterans in their districts are facing long waits for community care. In June, 10 Congresspeople from Washington told the department that their constituents were waiting two months for the VA to arrange health care visits and receiving little communication about the delays.

“We request your immediate action to resolve these issues and improve access to care,” the letter said.

Washington representative Dan Newhouse, who co-authored the letter, said Veterans account for roughly half of the calls he receives from residents in his rural district. The VA never responded to the concerns he and his colleagues raised.

“This is an effort to get closer to perfection on something that I think overall has been a big improvement, but can be better,” Newhouse said. “We all want to do better for our Veterans.”

Congresspeople from both political parties said the VA does a good job delivering health care, and pointed out that many of their constituents love the medical services they receive. A VA survey shows 90% of patients would recommend the health care system to another Veteran.

The VA performs as well as private hospitals on measures of quality, including cancer screenings and blood pressure control. Compared to civilians in the private sector, Veterans face shorter wait times to see VA doctors.

But like in every hospital system, some patients will need treatment the VA can’t provide.

The federal department dates back more than a century and has its roots in the Revolutionary War. For decades, the VA has purchased private care to help ailing Veterans.

“In most medical centers, there’s something they’re going to have to refer you out for at some point,” said Gallucci from VFW. “It’s unrealistic to think that VA can provide everything.”

Gallucci served eight years in the U.S. Army Reserve and was deployed to Iraq in 2003. Now, he helps other former service members access benefits through the VA.

“It’s not a question of, ‘Is VA care or community care better?’" Gallucci said. “It’s about how do these systems complement each other, how do they work to effectively deliver care that Veterans need?”

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NEWARK, N.J. – Three men today admitted their roles in a health care fraud and kickback schemes, U.S. Attorney Rachael A. Honig announced.

Nicholas Defonte, 73, and Christopher Cirri, 63, both of Toms River, New Jersey, and Pat Truglia, 53, of Parkland, Florida, each pleaded guilty before U.S. district Judge Kevin McNulty in Newark federal court to conspiracy to commit health care fraud.

According to documents filed in these cases and statements made in court:

Each defendant played a role in defrauding health care benefit programs by offering, paying, soliciting, and receiving kickbacks and bribes in exchange for completed doctors’ orders for durable medical equipment, namely orthotic braces (DME orders):

• Truglia and his conspirators had financial interests in multiple DME companies. The DME companies paid kickbacks to suppliers of DME orders, including Cirri, Defonte, and Truglia, in exchange for DME orders, which the DME companies subsequently fraudulently billed to Medicare, TRICARE, CHAMPVA, and other health care benefit programs. Truglia and his conspirators concealed their ownership of the DME companies by using straw owners who were falsely reported to Medicare as the owners of the companies.

• Truglia, Cirri, Defonte, and their conspirators owned and operated multiple call centers through which they obtained DME orders for beneficiaries of Medicare and other federal health care programs. The call centers paid illegal kickbacks and bribes to telemedicine companies to obtain DME orders for these beneficiaries. The telemedicine companies then paid physicians to write medically unnecessary DME orders. The DME orders were provided to DME supply companies owned by Truglia and others in exchange for bribes. The DME supply companies in turn provided the braces to beneficiaries and fraudulently billed the health care programs.

• Cirri, Defonte, and their conspirators had business relationships with call centers through which they obtained prescriptions for compounded medications and other medical products reimbursable by federal and private health care benefit programs. Cirri and Defonte provided these prescriptions for compounded medical prescriptions and other medical products in exchange for kickbacks and bribes from companies that fraudulently billed them to health care programs.

The defendants caused losses to Medicare, TRICARE, and CHAMPVA of approximately $50 million.

The charge of conspiracy to commit health care fraud is punishable by a maximum potential penalty of 10 years in prison and a fine of $250,000, or twice the gross profit or loss caused by the offense, whichever is greatest. Sentencing for all three defendants is scheduled for March 22, 2022.

Acting U.S. Attorney Honig credited special agents of the FBI, under the direction of Special Agent in Charge George M. Crouch Jr. in Newark; the Department of Health and Human Services-Office of Inspector General, under the direction of Special Agent in Charge Scott J. Lampert; the U.S. Department of Defense, Office of the Inspector General, Defense Criminal Investigative Service, under the direction of Special Agent in Charge Patrick J. Hegarty; and the U.S. Department of Veterans Affairs, Office of Inspector General, under the direction of Special Agent in Charge Christopher F. Algieri, with the investigation leading to the guilty pleas.

The government is represented by Assistant U.S. Attorneys Sean M. Sherman and Ryan L. O’Neill of the Opioid Abuse Prevention & Enforcement and Health Care Fraud Units in Newark, Senior Trial Counsel Barbara Ward of the Asset Recovery and Money Laundering Unit in Newark, and Trial Attorney Darren Halverson of the Criminal Division’s Fraud Section.

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Military families are worried that with changes coming to the military health system that include outsourcing some care to community providers, they won't be able to find quality providers or access decent care.

In some locations, families already are facing problems, said members of the Defense Department's Military Family Readiness Council Wednesday. For example, at Newport, R.I., military personnel face difficulties finding good pediatricians for their children, while in Europe, service members and their dependents have had trouble accessing mental health services, including via telemedicine.

They also worry that as the Defense Department pursues plans to restructure the military health system, the problems will get worse.

"We are having difficulty finding quality providers that are in the network. Is there anything being done to encourage civilian providers to participate with Tricare, or is there any real incentive for them to work with Tricare?" asked Jill Waters, a pediatric nurse and wife of an Army recruiter in Michigan, speaking to Defense Health Agency Director Lt. Gen. Ronald Place.

"We're just not sure what the future will hold," added Carolyn Stevens, director of DoD's office of Military Family Readiness Policy.

Since 2013, the Defense Department has undertaken efforts to restructure what was once a $50 billion health care system. The stated goal of the effort is to improve services while reducing costs by cutting redundant programs and systems that existed in triplicate under separate Army, Navy and Air Force medical commands.

But that effort grew substantially under the fiscal 2017 National Defense Authorization Act, which gave administrative authority of military hospitals and clinics to the Defense Health Agency and subsequently realigned the service medical commands to shift their focus toward caring primarily for active-duty personnel.

The transformation plans call for reducing the number of civilian beneficiaries, including retirees and their family members, seen at military hospitals in locations where comparable health care services are available in the local community under Tricare.

But as DHA and the services pursue these sea changes, troops and families are trying to sort out what health care services will be available down the road.

Sergeant Major of the Marine Corps Troy Black said Wednesday that changes at Naval Hospital Beaufort, S.C., which serves Marine Corps Recruit Depot Parris Island, have put the Marine Corps in the position of relying on community care for its recruits.

The aging hospital facility had already closed its emergency room and urgent care facilities. Under the DHA transformation plans, it’s slated to become an outpatient ambulatory care clinic with no overnight beds.

Marine officials have been concerned that personnel will face long wait times for emergency care at the local hospital or recruits will need to be transported to major medical centers farther away.

"I use [the recruit depot] as one example to highlight some of the challenges we're looking at with network care... having to rely on a civilian facility, there are challenges," Black said. "As we go through this over time, as we develop, how do we see this as being a priority? How does the military leadership influence the civilian leadership of those hospitals? How do we balance out major level training as a priority, accessions as a priority?" Black said.

Families also said they not only had questions about access to care but how they were supposed to meet military medical requirements such as being cleared for travel for overseas orders or qualifying for the Exceptional Family Member Program under a new system.

Place sought to assuage concerns, first noting that he, his wife, children and grandchildren are all beneficiaries in the military and Tricare systems.

"When I look at quality in our system, safety in our system, access or transparency, everywhere I look, I look at it as a surgeon, but I look at it as a patient, as a husband, as a parent and as a grandparent... I also understand the stress the entire family bears," he said.

He added that medical requirements for families will be improved once the process for meeting them is standardized across the services -- one of the goals of transformation.

"We're not there yet, but I fully understand the requirements to the Defense Health Agency standardize the process,'' Place said.

Regarding concerns over the availability and quality of providers in the Tricare networks, Place said several regulations restrict DoD's ability to recruit doctors or work with hospital systems directly, including on the contracts for managed care with Humana Military and Health Net Federal Services, the companies that oversee Tricare, and reimbursement rates linked to Medicare rates.

"In general, Those hospitals and doctors... that are in our networks are doing it out of a sense of patriotism. They are not making huge cash off of us," Place said. "We try to extol the virtues of our patient populations, that they are generally healthy, that they are motivated, that they are patriotic themselves. [And] in many areas of the country that's actually a successful marketing tool for which we are able to get high quality hospitals and practitioners. The limitations [are] where the market is tight, [the rates] can harm us."

How the COVID-19 pandemic will affect the system's overhaul has yet to be determined. On March 25, Defense Health Agency officials said they decided to delay the next step in the reforms -- establishing administrative markets responsible for military treatment facilities in five regions across the U.S.

But Place said he wishes the transformation could move more quickly and the plan will maintain "greater access to high quality care for every single beneficiary."

After the meeting -- the first Military Family Readiness Council meeting held virtually -- Patty Barron, a council member and director of the family readiness directorate at the Association of the United States Army, said she appreciated Place's overview but said military families are craving specifics.

She added that the "'What's next?' was not answered."

"Military families will deal with what you tell them if you can be as specific as possible," she said, saying she was speaking as a spouse and not for the council. "What we need is a FAQ on this. We have one for COVID-19, why not for this?."

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NEWARK, N.J. – Two Florida men have been indicted for their roles in durable medical equipment and compound medication schemes involving kickbacks and fraud, Acting U.S. Attorney Rachael A. Honig announced.

Thomas Farese, 79, of Delray Beach, Florida, and Domenic J. Gatto Jr., 47, of Palm Beach Gardens, Florida, are charged in an 11-count indictment with conspiracy to commit wire fraud, conspiracy to commit health care fraud, health care fraud, conspiracy to transact in criminal proceeds, transacting in criminal proceeds, and conspiracy to violate the federal Anti-Kickback Statute.

According to documents filed in the case and statements made in court:

Farese and Gatto played key roles in a scheme to defraud health care benefit programs by offering, paying, soliciting, and receiving kickbacks and bribes in exchange for doctors’ orders for durable medical equipment (DME) without regard to medical necessity, namely orthotic braces. Farese, Gatto, and their conspirators had financial interests in multiple DME companies that paid kickbacks to suppliers of DME orders, in exchange for DME orders. The suppliers, in turn, used telemedicine companies to obtain DME orders without regard to medical necessity. The DME companies owned by Farese and Gatto subsequently fraudulently billed Medicare, TRICARE, CHAMPVA, and other health care benefit programs for the DME orders. The defendants concealed their ownership of the DME companies by using straw owners who were falsely reported to Medicare as the owners of the companies. Gatto also brokered a kickback relationship whereby he received an illegal kickback each time specific DME suppliers provided DME orders to the DME companies controlled by him and his conspirators. Gatto and his conspirators then laundered the proceeds of the scheme through several layers of bank accounts under their control.

Gatto and his conspirators entered into a related kickback scheme involving prescriptions for compounded medications. They agreed that suppliers of compounded medications would receive kickbacks in exchange for submitting the orders to the pharmacies with whom Gatto and his conspirators had relationships. Gatto also agreed with others that he would receive kickbacks from those pharmacies for the compounded medication orders submitted by those suppliers. The compounding pharmacies then billed Medicare for the compounded medication orders.

The defendants caused losses to Medicare, TRICARE, and CHAMPVA of approximately $25 million.

The charge of conspiracy to commit wire fraud is punishable by a maximum potential penalty of 20 years in prison. The charges of conspiracy to commit health care fraud, health care fraud, conspiracy to transact in criminal proceeds, and transacting in criminal proceeds are each punishable by a maximum potential penalty of 10 years in prison per count. The charge of conspiracy to violate the federal Anti-Kickback Statute is punishable by a maximum potential penalty of five years in prison. he maximum fine for each count is $250,000, or twice the gross profit or loss caused by the offense, whichever is greatest.

Acting U.S. Attorney Honig credited special agents of the FBI, under the direction of Special Agent in Charge George M. Crouch Jr. in Newark; the Department of Health and Human Services-Office of Inspector General, under the direction of Scott J. Lampert; the U.S. Department of Defense, Office of the Inspector General, Defense Criminal Investigative Service, under the direction of Special Agent in Charge Patrick J. Hegarty; and the U.S. Department of Veterans Affairs Office of Inspector General, under the direction of Special Agent in Charge Christopher F. Algieri, with the ongoing investigations.

The government is represented by Assistant U.S. Attorneys Sean M. Sherman of the Opioid Abuse Prevention & Enforcement Unit in Newark, Ryan L. O’Neill of the Health Care Fraud Unit in Newark, Senior Trial Counsel Barbara Ward of the Asset Recovery & Money Laundering Unit in Newark, and Trial Attorney Darren Halverson of the Health Care Fraud Unit of the Criminal Division’s Fraud Section.

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Two men were sentenced in federal court Wednesday for helping orchestrate a scheme where physicians received kickback payments in exchange for writing and referring expensive compounded drug prescriptions to OK Compounding, announced U.S. Attorney Clint Johnson.

Johnathon Yates Boyd III, 50, of Katy, Texas, was sentenced to 12 months of probation and ordered to pay $391,475.41 in restitution. Bryan Fred Woodson, 61, of Beach City, Texas, was sentenced to 12 months of probation and ordered to pay $553,232.45 in restitution.

Boyd III and Woodson each pleaded guilty to conspiracy to pay kickbacks.

It is illegal to pay or receive “kickbacks” in conjunction with federal health care insurance. Prohibitions against kickbacks are crucial to ensure that financial motives do not undermine the medical judgment of physicians and other health care providers.

Boyd III and Woodson admitted to conspiring together with Christopher Parks, 60, of Jenks, and Dr. Gary Lee, 61, of Tulsa, to enrich themselves through the scheme at the expense of the federal government.

According to court documents, Boyd III and Woodson, formed R&A Marketing Group LLC around 2012. R&A Marketing introduced its recruited physicians to OK Compounding, a pharmacy controlled and operated by Parks and Lee, for the purpose of entering into a referral relationship with the pharmacy. The conspirators provided illegal kickbacks and bribes to the physicians, and in return, the physicians wrote expensive patient prescriptions for compounded drugs and referred those prescriptions to OK Compounding. The pharmacies then submitted large claims for payment of the costly prescriptions to various federal health care programs.

Physicians were allegedly provided pre-printed prescription pads that listed compounded formula choices. They would then check a box with their preferred selection then fax it directly to OK Compounding, rather than writing a prescription tailored to the patient who could then take it to a pharmacy of their choice.

Payments to physicians were disguised through various sham business arrangements. For example, physicians would enter into agreements with a pharmacy to serve as “medical directors” or “consulting physicians.” However, physicians did not provide any services to OK Compounding nor any other pharmacies controlled by Parks and/or Lee.

In exchange for recruiting physicians to enter into contracts as “medical directors” or “consulting physicians”, R&A Marketing was paid a commission based on the reimbursed prescriptions.

Compounding prescriptions is a practice in which a pharmacist or physician combines, mixes or alters ingredients of a drug or multiple drugs to create a medication that is tailored to the specific needs of a patient. These medications are prescribed when standard Food and Drug Administration (FDA) approved drugs are unsuitable for the patient. They are also more expensive and reimbursed at a far higher rate by federal and private insurance companies. Compounded drugs are not to be mixed or marketed in bulk.

OK Compounding is no longer in operation. Charges are currently pending against Parks and Lee. They are presumed innocent until proven guilty beyond a reasonable doubt in a court of law.

Veteran’s Affairs- Office of Inspector General, Defense Criminal Investigative Service, Department of Labor- Office of Inspector General (OIG), IRS- Criminal Investigation, U.S. Postal Service- OIG, FBI and the Department of Health and Human Services-OIG conducted the investigation. Assistant U.S. Attorneys Melody Noble Nelson and Richard M. Cella prosecuted the case.

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Two doctors who helped a local hospice agency scam Medicare were sentenced today to a combined 23 years in prison for healthcare fraud, announced U.S. Attorney for the Northern District of Texas Chad E. Meacham.

In May, a federal jury found Novus Health Services Medical Directors Dr. Mark E. Gibbs and Dr. Laila Hirjee, along with Novus RN Tammie Little, guilty of conspiracy to commit healthcare fraud and other charges. Today, Chief U.S. District Judge Barbara M.G. Lynn sentenced Dr. Gibbs to 13 years in federal prison and ordered him to pay $27,978,903 in restitution; she sentenced Dr. Hirjee to 10 years in federal prison and ordered her to pay $16,253,281 in restitution. The judge also sentenced Ms. Little to 33 months in federal prison.

According to evidence presented at trial, the defendants helped Novus CEO Bradley Harris defraud Medicare by, among other things, illegally admitting patients who were not appropriate for hospice and submitting materially false claims for hospice services.

Mr. Harris, who pleaded guilty prior to trial, testified against his former employees.

He told the jury that instead of relying on the expertise of licensed medical professions, he and Novus nurses determined which patients would be admitted to or discharged from hospice care, as well as which drugs and dosages they would receive.

They relied upon Novus doctors, including Dr. Gibbs and Dr. Hirjee, to certify that they had examined these patients face-to-face, when no such examinations had occurred, Mr. Harris testified.

Witnesses also testified that Dr. Hirjee and Dr. Gibbs engaged in the prescription of Schedule II controlled substances, such as morphine, hydromorphone, and fentanyl, by pre-signing blank C2 prescriptions and giving those to Brad Harris and others at Novus to let them prescribe controlled substances without any physician oversight.

As Director of Operations Melanie Murphey testified on day five of trial, “I was the doctor.”

Mr. Harris and the nurses used pre-signed prescription pads, prepared by Dr. Gibbs, Dr. Hirjee, and other Novus doctors, to dispense medications like morphine to patients. When Medicare suspended payment to Novus over concerns about billing, Mr. Harris, Dr. Gibbs, and others moved patients and employees to a new hospice company and continued to bill Medicare for hospice services.

In total, Medicare and Medicaid paid the Novus entities approximately $40 million dollars for hospice services before the companies were shut down.

“These doctors allowed Bradley Harris – an accountant with no medical expertise – to dispense controlled substances like candy, with little to no medical oversight,” said U.S. Attorney Chad Meacham. “They claimed to have had hands-on experience with hospice patients, when in fact, they’d entrusted life-or-death medical decisions to untrained businesspeople. We are satisfied to know they will spend the next decade behind bars.”

“The defendants violated their Hippocratic Oath as doctors and instead focused on lining their pockets at the expense of patient safety. This case highlights the importance of thoroughly investigating any complaint of healthcare fraud,” said FBI Dallas Special Agent in Charge Matthew DeSarno. “We encourage the public to help us identify, investigate, and prosecute this crime. If you suspect health care fraud, report it to the FBI at tips.fbi.gov, 1-800-CALL-FBI, or contact your health insurance provider.”

Several of their codefendants – Novus CEO Brad Harris, his wife, Novus Vice President of Patient Services Amy Harris, Novus Director of Operations Melanie Murphy, Novus Medical Director Charles Leach, Novus Medical Director Reziuddin Siddique (deceased), Novus Vice President of Marketing Samuel Anderson, Novus Director of Marketing Slade Brown, Novus RN Jessica Love, Novus triage RN Patricia Armstrong, Novus LVN Taryn Stewart, and Ali Rizvi, the owner of a separate physician home visit company – pleaded guilty to various offenses prior to trial. Love was sentenced 102 months, Stuart was sentenced to 96 months, Armstrong was sentenced to 84 months, Dr. Leach was sentenced to 57 months, and Anderson was sentenced to 33 months. The remaining defendants are facing statutory maximums of between two and 14 years in federal prison.

The Federal Bureau of Investigation’s Dallas Field Office, the U.S. Department of Health & Human Services Office of Inspector General (HHS-OIG), and the Texas Attorney General’s Medicaid Fraud Control Unit conducted the investigation. Assistant U.S. Attorneys Donna Strittmatter Max and Marty Basu are prosecuting the case with Assistant U.S. Attorneys Stephen Gilstrap, Gail Hayworth, and Brian McKay.

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SAN ANTONIO – This week, two San Antonio residents were sentenced for their roles in health care fraud schemes. Yesterday, Nancy Almaguer, 42, was sentenced to 18 months in prison and today, Christopher Felix Montoya, 47, was sentenced to two 18-month prison sentences to run consecutively.

According to court documents, Montoya was a licensed physician’s assistant and owner of TPC Family Care and Medical Clinics in San Antonio and Laredo. Almaguer was the Chief Operating Officer for the clinics. Beginning in September 2018 through June 2019, Montoya and Almaguer agreed to refer lab testing requests to specific laboratories. The labs billed insurance programs, including Medicare and TRICARE, and paid Almaguer and Montoya a percentage of their receipts in return for the referrals. The kickback schemes resulted in over $500,000 in billings to public and private insurance companies.

In July and September of 2021, Montoya and Almaguer, respectively, pleaded guilty to one count of conspiracy to defraud the U.S. and to pay and receive health care kickbacks.

In a separate case, in July 2021, Montoya pleaded guilty to one count of conspiracy to receive health care kickbacks. In this case, Montoya admitted that for five months beginning in February 2015 he received kickbacks to write prescriptions for compounded medication from a California-based pharmacy that had high TRICARE reimbursements. Based on the evidence, TRICARE was billed $8,832,268.73 for prescriptions Montoya wrote to which TRICARE paid out $6,690,598.77.

In addition to the prison sentence, Almaguer was ordered to forfeit $137,792.10 in criminal proceeds and pay $52,603.62 in restitution. Montoya was ordered to pay a total of $849,865.93 in restitution.

“Kickback regulations exist to protect patient choice and ensure that only medically necessary procedures are performed,” said U.S. Attorney Ashley C. Hoff. “Our office continues to help protect federal insurance programs from fraud. We hope that these sentences communicate that these regulations should be taken seriously.”

“Health care fraud significantly harms the U.S. economy by costing this country billions of dollars a year,” said FBI Special Agent in Charge Christopher Combs. “Those losses result in rising medical costs for all Americans. The FBI is committed to investigating those involved in this crime through investigative partnerships with other federal agencies.”

The FBI; Texas Attorney General’s Office Medicaid Fraud Control Unit; U.S. Department of Health and Human Services—Office of Inspector General; the U.S. Office of Professional Management—Office of Inspector General; and the Defense Criminal Investigation Service investigated this case.

Assistant U.S. Attorneys Justin Chung and William R. Harris prosecuted this case on behalf of the government and Assistant U.S. Attorney Antonio Franco handled the forfeiture aspects.

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Tampa, Florida – U.S. District Judge Virginia M. Hernandez Covington has sentenced Michael Nolan (48, Tampa) and Richard Epstein (29, Aurora, CO) for their roles in a conspiracy to defraud federal health benefit programs, Medicare and the Civilian Health and Medical Program of the Department of Veterans Affairs (“CHAMPVA”).

Nolan was sentenced to six years and six months in federal prison, followed by three years of supervised release. Epstein was sentenced to five years and three months in federal prison, followed by three years of supervised release. As part of their sentences, the court also entered a money judgment against each defendant in the amount of $2.1 million and $3 million, respectively, which were proceeds of the conspiracy. Noland and Epstein were also ordered to pay restitution, jointly and severally with each other and other conspirators, in the amount of $29,020,304.

Nolan and Epstein each had pleaded guilty on July 31, 2020.

According to court documents, from around October 2016 through around April 2019, Epstein and Nolan ran a telemarketing company in Tampa called REMN Management LLC that targeted the elderly to generate thousands of medically unnecessary physicians’ orders for durable medical equipment (“DME”) and cancer genetic testing (“CGx”). Epstein and Nolan also created and operated Comprehensive Telcare, LLC, a “telemedicine” company through which they illegally bribed physicians to sign the orders regardless of medical necessity. Epstein and Nolan then illegally sold the signed physicians’ orders to client-conspirators for use as support for false and fraudulent claims submitted to Medicare and CHAMPVA. The conspiracy resulted in the submission of at least $134 million in fraudulent claims to the federal health benefit programs, resulting in approximately $29 million in payments.

The investigation and prosecution of the case were a joint effort between the Middle District of Florida and the Department of Justice - Criminal Division, Fraud Section, Health Care Fraud Unit, as part of nationwide actions known as Operation Brace Yourself and Operation Double Helix. The operations targeted ongoing schemes, such as the conspiracy described above, in which DME companies, laboratories, and marketers were paying illegal bribes through “telemedicine” operators to secure signed physicians’ orders for DME and CGx, which were then used as support for fraudulent, illegal claims submitted to Medicare and other federal health benefit programs.

“These significant sentences and restitution of over $29,000,000 to our nation’s critical healthcare system – Medicare – are a result of law enforcement’s unified efforts to hold the perpetrators of one of the largest healthcare fraud schemes in history accountable for their crimes,” said Special Agent in Charge Omar Pérez Aybar of U.S. Department of Health and Human Services Office of Inspector General.

“We are all victims of these corrupt individuals because they cheated the taxpayer funded Medicare system,” said FBI Tampa Division Special Agent in Charge Michael McPherson. “Health care fraud investigations are given high priority within the FBI’s Criminal Investigative Division. Because this abuse impacts us all, protection of these federal health benefit programs is a shared responsibility which can be accomplished with the support of an engaged community willing to bring health care fraud to the attention of law enforcement.”

“Today’s sentence properly holds these defendants accountable for their fraudulent actions and reflects the magnitude of the crime committed against CHAMPVA and Medicare,” said Special Agent in Charge David Spilker of the Department of Veterans Affairs Office of Inspector General’s Southeast Field Office. “The VA OIG’s continued oversight of VA’s multiple healthcare programs, including CHAMPVA, is one of the agency’s highest priorities. We thank our outstanding law enforcement partners for their efforts in this joint investigation.”

"The significant prison terms and financial penalties will hopefully bring some closure to those victimized by Nolan and Epstein,” said IRS Criminal Investigation Special Agent in Charge Brian Payne. “They preyed on the elderly and military Veterans to subject them to unnecessary medical testing and to use unnecessary medical equipment for their own financial gain. We will continue to investigate these con artists and hold them accountable.”

This case was investigated by U.S. Department of Health and Human Services – Office of Inspector General, the Federal Bureau of Investigation, the Department of Veterans Affairs – Office of Inspector General, and the Internal Revenue Service –Criminal Investigation, Tampa Field Office. The criminal case is being prosecuted by Assistant United States Attorneys Tiffany E. Fields, Jay G. Trezevant, James A. Muench, and Department of Justice Trial Attorney Gary A. Winters.

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Fox Chase-area Pharmacy was the Top Retail Purchaser of Oxycodone in Pennsylvania

PHILADELPHIA – United States Attorney Jennifer Arbittier Williams announced that the United States filed a civil lawsuit against Philadelphia-based pharmacy Spivack, Inc., which previously operated under the name Verree Pharmacy, and its former owner, pharmacist Mitchell Spivack, alleging that they engaged in a years-long practice of illegally dispensing opioids and other controlled substances, and systematic health care fraud. The lawsuit alleges that Verree and Spivack illegally dispensed unparalleled quantities of opioids and other controlled substances into the Philadelphia community. The complaint seeks civil penalties and civil damages, which could total in the millions of dollars, as well as injunctive relief.

The culmination of a multi-year federal-state investigation, the complaint alleges that Verree Pharmacy, its pharmacist and then-owner Mitchell Spivack and other employees of Verree, had a responsibility to dispense opioids and other controlled substances only when appropriate. Instead, the United States alleges that the pharmacy and Spivack dispensed the drugs, even when faced with numerous red flags suggestive of diversion—such as opioids in extreme doses, dangerous combinations of opioids and other “cocktail” drugs preferred by those struggling with addiction, excessive cash payments for the drugs, blatantly forged prescriptions, and other signs that the pills were being diverted for illegal purposes. The complaint alleges that Verree—which was the top retail pharmacy purchasing oxycodone in Pennsylvania—has been a nationwide and regional outlier in its deviant purchasing, dispensing, and billing of controlled substances. To avoid scrutiny from the drug distributors that sold them the pills, Verree through Spivack, allegedly made false statements to maintain the façade of legitimacy and keep the pharmacy stocked with these pills critical to its profits. Behind that façade, the complaint alleges that Spivack drew millions of dollars from the pharmacy while the public suffered the consequences, including one patient who overdosed and died next to Verree Pharmacy bottles dispensed by Spivack.

The United States’ complaint alleges that Verree and Spivack were also engaging in an expansive health care fraud scheme involving fraudulent billings for drugs not actually dispensed. The alleged cornerstone of the scheme was a code used by the pharmacy employees in their internal computer system: “BBDF” or “Bill But Don’t Fill.” Verree, Spivack and their co-conspirators allegedly used BBDF as a means to cover their losses on other drugs and further line their pockets with illicit profits by falsely claiming to insurers, including Medicare, that they had dispensed a drug to a patient, when in fact they had not. According to the complaint, this sophisticated fraud—which one of the employees admitted to investigators—resulted in significant losses to Medicare and other federal programs.

The lawsuit seeks to impose civil penalties and damages on Verree and Spivack under the Controlled Substances and False Claims Acts. If Verree and Spivack are found liable, they could face civil penalties up to $68,426 for each unlawful prescription dispensed, civil penalties up to $23,607 for each false claim they submitted to federal health care programs, and treble damages for the alleged health care fraud against federal programs. The court may also award injunctive relief to prevent Verree and Spivack from committing additional controlled substance violations.

“Pharmacies and pharmacists engage in the deepest violation of the community’s trust when they exploit their access to opioids and other controlled substances and illegally dispense the drugs for their own financial gain,” said U.S. Attorney Williams. “It is even more disturbing when pharmacies take advantage of their position of trust by fraudulently billing Medicare and other federal health care programs for bogus prescription drugs. My Office will use every resource it has to pursue and hold these individuals accountable. I am grateful for the support and investigative teamwork that the DEA, HHS-OIG, and the Pennsylvania Attorney General’s Office provided in this important matter.”

“In a city that has been so adversely and disproportionately affected by the opioid epidemic, Verree Pharmacy was the top retail pharmacy purchasing oxycodone in the entire state of Pennsylvania,” said Thomas Hodnett, Special Agent in Charge of the Drug Enforcement Administration’s (DEA) Philadelphia Field Division. “Spivack and the other employees at Verree routinely demonstrated total disregard for their professional and ethical obligations and improperly dispensed powerful painkillers when numerous warning signs were present.”

“The Medicare and Medicaid Programs provide vital prescription drug services to their beneficiaries, said Maureen R. Dixon, Special Agent in Charge of the Philadelphia Regional Office for the Department of Health and Human Services, Office of Inspector General. “Pharmacies are required to only bill for prescriptions and products they actually provide to their patients. HHS-OIG will continue to work with the U.S. Attorney’s Office, the Pennsylvania Attorney General’s Office, and the DEA to investigate allegations of fraudulent insurance billings.”

“We know that nearly 80% of those who use heroin first started with misusing a prescription opioid,” said Attorney General Josh Shapiro. “Pharmacies and medical professionals have a responsibility under the law to dispense these drugs only when appropriate. These allegations of illegal dispensing and fraud are disturbing -- they hurt families and communities all over the Commonwealth and steal needed resources from taxpayers. Our office is committed to continuing to work with our federal partners, and I am thankful for the women and men who collaborated on this case.”

If the public has any information regarding Verree Pharmacy or any other health care fraud allegation, individuals should contact the HHS-OIG hotline at 800-HHS-TIPS.

The case is being investigated by the Philadelphia Field Division of the Drug Enforcement Administration, HHS-OIG, and the Pennsylvania Office of the Attorney General, with additional assistance from the Office of Personnel Management Office of Inspector General, the Defense Health Agency, and the Defense Criminal Investigative Service. The civil investigation and litigation are being handled by Assistant United States Attorney Anthony D. Scicchitano and auditors Dawn Wiggins and George Niedzwicki.

The complaint contains allegations only that the United States must prove if the case proceeds to trial.

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U.S. Seeks to Recover Hundreds of Millions of Dollars

NASHVILLE – The United States today filed a complaint in intervention alleging violations of the False Claims Act (FCA) and the Anti-Kickback Statute (AKS) by Methodist Le Bonheur Healthcare (MLH) and Methodist Healthcare Memphis Hospitals (collectively, Methodist), for paying unlawful kickbacks to West Clinic, P.C. (West) in exchange for West’s patient referrals, announced U.S. Attorney Mark H. Wildasin for the Middle District of Tennessee.

The government began investigating the wrongdoing alleged in today’s complaint in response to a lawsuit filed under the qui tam, or whistleblower, provisions of the False Claims Act, which allows private citizens with knowledge of false claims to bring civil suits on behalf of the government and to share in any recovery. The qui tam action was initially filed on May 30, 2017, by Jeffrey H. Liebman, the former President of Methodist University Hospital. In December 2019, David M. Stern, M.D., the former Executive Dean and Vice Chancellor at the University of Tennessee Health Sciences Center, who served on the Board of Directors of MLH from 2011 to 2017, joined the lawsuit. Stern was also a member of the Executive Cancer Council and the Steering Committee for the West Cancer Center.

The complaint sets forth in detail the unlawful kickbacks, disguised through a sophisticated business integration wherein Methodist purchased substantially all of the outpatient locations of the largest oncology practice in the Memphis area, owned by West. At the time of the arrangement, Methodist lacked a comprehensive cancer treatment center.

The multi-agreement transaction purported to be a lawful way to allow West’s patients to be treated at Methodist locations by West-employed physicians for outpatient and inpatient services, with West providing management services to Methodist’s adult oncology service line. As a result of the deal, Methodist would receive increased Medicare reimbursements relating to the cancer care. The parties described it as a “partnership” to achieve a cancer “center without walls,” where patients would go to Methodist-owned facilities for all their cancer-related care in what was called the West Cancer Center. However, there was never any formal partnership created, as to do so likely would have violated regulatory requirements.

As part of Methodist’s business combination with West, Methodist made a separate for-profit $7 million investment in ACORN Research, LLC (ACORN), an entity in which West and its Medical Director and shareholder, Dr. Lee Schwartzberg, had a personal financial interest. Through the deal, Methodist provided an immediate influx of millions of dollars in cash to West through its purchase of certain assets, as well as the ACORN investment, which resulted in a repayment of $3.5 million in debt owed to West and its shareholder, Dr. Schwartzberg. Kickbacks for the revenues Methodist generated from the West referrals, however, were disguised as payments Methodist made to West during the seven years of the deal, and expressly for certain services that were supposed to be – but were not – provided under the management services agreement.

As a result of the transaction, Methodist, which prior to the deal had no outpatient cancer treatment, was able to establish a new stream of income in the reimbursements for outpatient treatment that previously went to West. Methodist also realized a huge increase in referrals for inpatient services from West, which previously referred the bulk of its patients to Methodist’s competitors, including Baptist Memorial Hospital.

By purchasing West’s outpatient locations, Methodist was able to bill Medicare not only for the facility and professional components of outpatient treatment but also for the chemotherapy and other drugs provided, for which Methodist could recoup a staggering discount in costs through the 340B Discount Drug Program, resulting in $50 million in profits to Methodist in one year alone.

Methodist knew that it would be a violation of the AKS to compensate West in exchange for the volume or value of referrals to Methodist, yet, as the referrals to Methodist increased over the seven years of the deal, so did Methodist’s payments to West under the management agreement.

Methodist also knew that West had not been providing all the management services at all the locations required by the MSA. For the management services West was performing, Methodist often was double-paying West, as it was paying West separately for these services pursuant to other agreements.

In sum, Methodist knowingly agreed to pay West millions of dollars in kickbacks for the revenues Methodist expected to, and ultimately did, realize from West’s referrals. The arrangement lasted from January 1, 2012, through December 31, 2018, and continued even after Methodist knew that the United States was investigating these allegations following the filing of the whistleblowers’ lawsuit.

The matter is being investigated by the Department of Health and Human Services, Office of Inspector General. Assistant U.S. Attorney Kara F. Sweet represents the United States.

The claims in which the United States has intervened are allegations only, and there has been no determination of liability. The lawsuit is captioned United States of America ex rel. Jeffrey H. Liebman and David M. Stern, M.D. v. Methodist Le Bonheur Healthcare, et al., Case No. 3:17-cv-00902 (M.D. Tenn.).

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Despite years of significant budget increases, the Department of Veterans Affairs will need billions in additional funding in fiscal 2023 to keep pace with the health care and support services needs of Veterans and their families, according to a new report released by advocacy groups today.

The Independent Budget — an advisory spending plan compiled by Disabled American Veterans, Paralyzed Veterans of America and the Veterans of Foreign Wars — calls for a 23 percent increase in VA program spending over the latest White House request in order to boost money for priorities like mental health services, caregiver support, and homeless Veterans assistance.

The figure is likely to draw concerns from lawmakers who have grumbled about the ever-rising VA budget in recent funding cycles.

In fiscal 2001, the entire VA budget totaled about $45 billion. By fiscal 2011, it was about $125 billion, almost triple that total. Ten years later, in 2021, the department’s budget was nearly double that again, at $245 billion.

The White House budget request for fiscal 2022 — which began last October — sits at $270 billion. Lawmakers have not yet approved a full-year budget for the department, but are expected to advance discussion on that issue in coming weeks.

The administration’s fiscal 2023 budget plan for VA is expected to be released sometime next month.

Authors of the Independent Budget said their calls for even more VA money next year aren’t wishful thinking but a real assessment of the challenges ahead for the department.

“As we enter into 2022, COVID’s impact remains a challenge for VA, with the spread of the virus and disruptions to health care systems continuing,” said Randy Reese, executive director of DAV’s Washington Headquarters.

“In this environment, we made cautious recommendations based on historical trends to ensure the needs of our nation’s ill and injured Veterans are met.”

Under the Independent Budget plan, VA officials would see a $1.8 billion boost to health programs to “close the gap in clinical care” at department medical centers.

“The lack of adequate health care staffing has been a major driver of longer waiting times for Veterans seeking VA care, and ultimately has the effect of suppressing the true level of Veterans’ demand for care,” the report states. “It also forces many Veterans who would prefer to receive their care from VA providers into community care providers.”

The groups also want to add $490 million above the pending White House request for caregiver support programs, $395 million more for homeless Veterans’ programs, and $288 million more for mental health services and suicide prevention efforts.

The advisory budget also calls for an extra $3.8 billion for major and minor construction programs — an issue that the groups have been pushing for years, but one that has largely gone unanswered in White House budget plans.

The Independent Budget focuses only on discretionary spending, and not mandated increases in benefits that federal planners must account for in their own fiscal plans.

As such, the document isn’t an exact blueprint of what the final VA budget proposal would look like, but it does serve as an important point of discussion for lawmakers as they enter their annual budget debates.

The authors noted their proposal is a snapshot of future VA needs at this moment, but lawmakers need to be wary of the ever-changing nature of the pandemic as they conduct their budget debates.

Given the uncertainty surrounding VA’s future resource needs, Congress and the Administration must regularly review and be prepared to adjust funding levels whenever necessary to ensure VA has sufficient resources to care for our nation’s Veterans,” the report states.

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The U.S. Department of Veterans Affairs (VA) today released survey results showing Veteran trust in VA health care outpatient services has increased more than 5% since 2017, reaching 90.1% as of April 12.

VA received surveys from 4,030,438 Veterans since June 2017 to the present via the Veterans Signals customer feedback program which asks Veterans about their care experience and to rate their trust in VA.

“These improvements are a testament to not only VA’s investment in patient experience programs but also the dedication of our employees.” said VA Secretary Robert Wilkie. “Even during a pandemic, our VA team has continued its steadfast commitment to delivering the highest quality care for our nation’s Veterans.”

This delivery of quality care reflects VA’s priority mission of customer service and its goal to ensure a positive patient experience. In the past three years, more than 95,000 Veterans Health Administration employees have been trained on VA’s customer experience training program called Own the Moment. VA has also implemented programs like Red Coat Ambassadors nationwide to improve the Veteran’s navigation of care facilities across the country. Initiatives such as VA Patient Experience Week (April 27-May 1) share best practices in culture changing patient experience tools, technology and training with institutions and providers across the country.

According to the Hospital Consumer Assessment of Healthcare Providers and Systems (HCAHPS), the results of these and other improvements, has been an increase in the VA patient experience by 4% in the past four years while private sector’s national average has increased by only 1%.

Since the VA began offering Veterans the option to respond to Veteran Signals surveys with free-text feedback, 68% (918,873) of their comments have been complimentary, 18.9% (255,351) have been concerns and 13.3% (179.902) are recommendations. VA uses this feedback at the national, regional and local levels to make improvements in the way VA provides care and services.

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Once again, Department of Veterans Affairs bureaucrats are making a concerted effort to prevent Veterans from using our health-care benefits at community-based providers outside the VA system — despite a law requiring them to do so. 

Seven years ago, while suffering from excruciating pain, I attempted to make a primary-care appointment at a VA hospital. In the week between Christmas and New Year’s, no one at my Durham, N.C., VA facility answered the phone. In January, it took two weeks to get a new provider assigned and an appointment scheduled. The earliest they could offer was April 15, 90 days out.  

At that point, inflamed joints throbbing, I asked if I could use my Choice card, which had arrived in November with the promise it gave me access to private, local health care in the event “the Veteran is told by his/her local VA medical facility that he/she will need to wait more than 30 days from his/her preferred date or the date medically determined by his/her physician.”

No dice.

The Veterans Choice Program was enacted by law in the wake of the 2014 VA wait-time scandal. Nevertheless, the VA denied me the Choice option until after my appointment in 90 days.

With the team at Concerned Veterans for America, I worked hard to help pass that bill and believed the program would make a difference. Alas, faceless bureaucrats undermined its implementation every step of the way.

So we went back to work.

In 2018, Congress passed and President Donald Trump signed the VA Mission Act, which bolstered Veterans’ health-care options, providing access standards that shortened the requirements for Veterans seeking private care to those who could not get a VA appointment within 20 days or who had to drive more than 30 minutes to a VA facility.

It was a positive reform. But again, we see VA bureaucrats working, despite the law, to limit Veterans’ ability to access care. 

In 2020, some Trump administration officials expressed public doubts about using community care during the COVID pandemic. That was all career bureaucrats needed to hear. It’s been on the rocks ever since.

After a lawsuit filed this year, the VA finally responded to Freedom of Information Act requests that it account publicly for wait times and Veterans’ ability to access community care. 

The results were startling and add to concern about the 20 million appointments that have been canceled, denied or delayed since the pandemic’s start.

The FOIA documents revealed the VA’s failure to follow the law and its own regulatory requirements as it refuses to refer eligible Veterans for community care, possibly cancels appointments without patient consent and dissuades Veterans from seeking community care in call scripts.

In January 2020 at the Prescott, Ariz., facility, for example, 10.3 percent of Veterans were listed eligible for primary care in the community when in fact 68 percent were eligible. The VA is also denying Veterans community care due solely to cost. That’s not part of the law, and getting Veterans the care they need should always be the top priority.

The Biden administration has sent clear signals it intends to accede to the bureaucrats’ wish to end community care.   

The Mission Act page on the VA Web site was recently removed. The VA has ceased providing Veterans easily accessible information about the program. And the department is dismantling the community-care office, integrating it into the general patient-management system. It’s blocked referrals to community care at every opportunity. 

Last month, it issued a call for input on access standards. Parts of the request for information are technical, but question No. 6 asks: “What are Veterans’ experiences with, and feedback on, the VA access standards established in 2019?” Might this be the first step in dismantling the program and ensuring that Veterans cannot seek VA-sponsored care in their communities?

“During the pandemic I had an appointment with the VA urologist as a follow-up because of elevated” prostate-specific antigen levels, a New York Veteran posted on the My VA Story Web site. “The VA canceled and rescheduled it four times until I asked why and was told they were only seeing patients on an emergency basis. My condition was probably not an emergency but I felt it was urgent enough that I transferred my records to a civilian urologist.”

The VA didn’t refer him. He paid out of pocket to get the care he needed — the care he’d earned. 

All Veterans deserve quality, timely care. When I was in pain, access to community care would have solved my situation sooner. Don’t let the VA take it away.

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As the 11th secretary of Veterans Affairs since President Ronald Reagan established it as a cabinet-level organization in 1988, Secretary Denis McDonough hardly has big shoes to fill.

Each secretary has made promises, and some have made changes: Jesse Brown expanded service to all veterans but particularly for women veterans, and he extended health care through a series of clinics. Edward Derwinski added some benefits for Vietnam veterans exposed to Agent Orange. Bob McDonald created the first Veterans Experience Office expressly to improve the us-against-them feeling so many veterans complain about.

But in the background, scandals arose. Eric Shinseki, beloved by his staff and by his boss, President Barack Obama, inherited a benefits backlog issue that went back years. It was first highlighted during the Walter Reed Scandal in 2007 under Secretary James Nicholson, when soldiers faced a Defense Department backlog in the military medical retirement system. After leaving the military and beginning VA’s benefits process, they then faced a second 400,000-plus case backlog at VA. Nicholson had also resigned.

Health benefits were denied to Gulf War veterans, Vietnam veterans, and veterans of the wars in Iraq and Afghanistan. Veterans killed themselves at high rates — and a VA official issued the infamous “shhh!” memo wondering if VA officials should issue a statement before someone “stumbled” on the problem. And 13,000 old benefits cases were found in a filing cabinet.

Most recently, Sec. Robert Wilkie, a President Donald Trump appointee, chose to discredit a House Veterans Affairs staffer and Navy reservist after she reported being groped and verbally assaulted at a VA facility in Washington — rather than look into the case and work to prevent it from happening again. Reporting from ProPublica led to a government investigation.

Each of those former secretaries made promises. They spoke of honoring veterans. They referred to Abraham Lincoln and the gratitude of a nation, and they laid wreaths and visited hospitals. And each time, veterans wondered what they could believe.

McDonough has come forward with a new set of promises: transparency. A proactive, rather than reactive, system. Again working for internal cultural change so veterans no longer chant: “Delay, deny … until you die.”

He runs a huge agency: More than 9 million veterans are enrolled in VA health care, which makes it the largest health care system in the United States. About 3.9 million veterans receive compensation for disabilities. About 424,000 people work for VA. And the president has requested almost $270 billion in funding for fiscal year 2022.

He knows the priorities: the burn pits. The backlog. The caregivers. Suicide rates and drug addiction and homelessness and transition, especially as veterans realize there isn’t a war to go to to avoid the problems that arise at home.

But we’ve heard these promises before. Why should we believe McDonough?

“You shouldn’t,” he tells The War Horse. “You shouldn’t.”

Still.

Enough changes have been made in the early days of McDonough’s term that even the veterans’ service organizations say they are, after years of expressing frustration, “hopeful.”

He has invited journalists, including The War Horse, in for one-on-one interviews. He holds monthly press conferences and quarterly breakfast meetings with the veterans’ service organizations. VA extended presumptive status to veterans with lung issues and some cancers related to exposure to burn pits. And McDonough seems willing to make decisions that could be hung up by controversy: He recently decided to offer gender confirmation surgery at VA facilities.

These may seem like minute changes, but in the past, journalists have struggled to get an interview for even “good news” stories out of VA. Veterans groups have complained about requests for meetings that haven’t even been acknowledged. And the burn pits? Army Times broke that story — and all of its associated health implications — in 2008.

Don’t let’s even get started about Gulf War illness.

So is it OK to hope? Is it time?

“Overall, Secretary McDonough has established laudable goals and principles to guide him,” Joy Ilem, national legislative director for Disabled American Veterans, told The War Horse by email. “Now we need to see them lead to real results for America’s veterans.”

The headlines haven’t all been good. Doctors with revoked licenses were approved to work at VA facilities. The agency has delayed implementation of its electronic health record program. And it has faced criticism of an ever-increasing budget.

In other words, McDonough still has some work to do, and he must do it within the confines of a bureaucracy built bit by bit. He must keep up the morale of the employees doing good work — and veterans surveys show there are a lot of them — while dealing with holdover employees who would like to see VA fail to prove government health care doesn’t work and that VA should be privatized. And he must still work within the rules prescribed by Congress.

“I’m not asking anybody to believe me on anything,” McDonough says. “I’m saying I’m here to be held accountable to what I said last month and last year. And I don’t know, I hope, I hope it works out. But you don’t need to believe me. This is why you guys are in business.”

‘I was not looking for a job’

The challenges, which must be among the most formidable in the U.S. government, as well as the failures of qualified people in the past, seem like a pretty good reason for someone with McDonough’s resume to say no. He served as President Obama’s chief of staff before going to work for the Markle Foundation. Why risk an impressive career when VA has tarnished so many in the past?

“Well, I was not looking for a job,” McDonough says. “And I was not looking to come back to the government. But the president of the United States asked.”

Fair, but the request is also a job requirement of each prior secretary, and others have said no — famously including Cleveland Clinic CEO Toby Cosgrove, who turned down Trump.

“That’s an insufficient answer,” McDonough says. “Because I’m also really glad he did ask.”

In the 20 years after the 9/11 attacks, McDonough worked behind the scenes making sure other people’s decisions were enacted — and that included sending young men and women to war in Iraq and Afghanistan. As VA secretary, he faces a new challenge of making the decisions, rather than following others’ orders. And, he says, he can “make good on the promises that we made those men and women whose life I had a part in impacting so profoundly.”

Because of his resume, and because of his family connections, he says he came to the job feeling well-informed. His wife, Kari McDonough, founded Vets’ Community Connections, a group that introduces civilians to veterans, and may be the reason Biden thought of him for the job, Denis McDonough says. When Denis McDonough worked for Obama, Kari McDonough volunteered for the Red Cross at Walter Reed National Military Medical Center and from there started to devote time to service members and their families.

But beyond his wife, he talked to friends who are service members and veterans, as well as former VA secretaries, such as McDonald, “whom I hold in very, very high regard, and whom I got to know quite well.” McDonald replaced Shinseki after it was revealed that veterans died while waiting for care, which made headlines on national news — and after McDonough himself made the rounds trying to calm an angry nation. Veterans groups urged Trump to keep McDonald on as VA secretary because of his push for transformation — including the Veterans Experience Office, which focused on asking veterans what they needed and used human-centered design to find problems in forms, processes, and even visits to the clinic. But Trump brought on David Shulkin, who worked under McDonald and who was fired after being accused of using government travel for personal use — which he has consistently denied and wrote in his book was really a ploy toward privatizing VA.

McDonough also learned, based on past secretaries’ experience, that he may not have a lot of time: A second term for President Joe Biden or another Democrat might lead to a second term for McDonough. A second term for Trump would likely mean another move toward privatization.

‘It’s become so difficult … so bureaucratized’

What McDonough learned from his mentors could strike fear into the heart of any government official. But he says he’s decided to focus on the veterans — and to do that by taking accountability for quick action.

“I think the general sense is that — which I think is an accurate sense — is that as a country, we dedicate to do a lot for veterans, as we should,” he says. “And the institution itself has grown up in a way that, if you were to step back and build it in its whole self, from scratch, you wouldn’t build it this way. It’s built in a very kind of step-by-step fashion.”

VA contains three administrations — three large administrations: the Veterans Benefits Administration, the Veterans Health Administration, and the National Cemetery Administration. Each leadership team likes to run things the way they’ve always run things — or at least without the help of the new guy in the front office. In other words, just like any large entity, change is hard, but at VA, it’s especially hard. And it’s hard to push information from administration to administration.

“So the structure itself creates a series of management challenges,” McDonough says.

The second big issue? “Given the importance of the mission, the expectations for excellence are very high,” he says. “And therefore, when we don’t meet that, there’s, I think, very understandable public frustration.”

Which leads to the third big issue: How does one lead people toward change — keep up morale, celebrate the wins, invigorate them toward future progress — if the public has a hard time seeing small innovations or real successes when veterans still kill themselves in VA parking lots or line themselves up in tents on Skid Row?

“I think that public frustration too often leads to a crisis of confidence,” McDonough says. “And, a lot of times, I feel like my job around here is to just hold up a mirror to people who are doing things really, really well. So they can see and be reminded of how well they’re doing those things.”

In each speech, he tries to mention a VA employee who does good work. He tells stories of successes. He reminds his team that the job is hard, but they’re in it together. Change isn’t easy: The new electronic records system — likely tied in with the frustrations of all health care workers dealing with COVID — has folks saying in a survey at one medical center that they’ve considered quitting. And while numbers have improved in recent years, staffing shortages still make everyone’s jobs harder. Open positions at the highest levels make it hard to plan for the future, including an undersecretary for health position — which has been open since 2017.

“One long-overdue action is for the administration to nominate, and then the Senate to confirm, qualified undersecretaries for health and benefits,” Ilem says. “Filling these key leadership positions must be among the highest priorities of this administration. No organization can operate at maximum efficiency when you have long-standing vacancies and temporary leaders at the top.”

And new human resources policies from the last administration may have made hiring that much more difficult, according to a new article from The American Prospect, a progressive political magazine. The program replaced local decision-makers with a web-based system at the regional level, meaning local health facilities have to wait, often months, for simple hiring decisions to be made. If this is a problem, a new undersecretary could potentially fix it.

“Fixing it” serves as the epitome of the problems in any bureaucracy, because it goes back to change management and getting buy-in, as well as enabling employees to take the ownership and the leadership needed to get things done. This isn’t necessarily common in a good-enough-for-government-work climate that years of feeling as if nothing will ever change can build.

Add to that the belief that one mistake — any mistake — could get an employee fired, as people have seen in the fate of their secretaries, and such fear-driven paralysis creates even bigger blockers. McDonough says he’s trying to change that by building confidence in his employees — both in their capabilities and in their belief that he has their backs if they try new things.

“Because it’s in the inconfidence or the nonconfidence that we make bad mistakes,” he says. “And we don’t take appropriate risk. And we get frozen by risk avoidance, rather than informed by risk management and risk tolerance.”

He takes it further, showing an understanding of just how difficult it is to make change for the people who work at VA:

“I think people here understand that they’re going to encounter frustration, and not only they understand that they’re going to encounter it, but that they understand that it’s hard-earned frustration, in some cases,” he says. “Because, oftentimes, among the most frustrated people are the people who work here trying to get stuff done, but it’s just become so difficult, so encumbered, so layered, so bureaucratized.”

For him, that brings pride in the employees who do break through, who have managed through a pandemic, and who do keep a sharp focus on the veterans — because he says he’s also keenly aware that they can go elsewhere. VA isn’t the only organization struggling to find employees in 2022.

So far, he says the internal change is going well.

“But you know, I don’t know yet,” he allows. “And inevitably, there’s going to be debate and discord, either at the interagency or here internally. In fact, I hope there is, because it’s out of that discord that, actually, greater knowledge comes.”

He knows not everyone will agree, but he says he hopes everyone will understand and believe in the process.

“There’s still delicate questions to resolve,” he says, “which is why we also have to make sure, among those stakeholders we’re talking to are the VSOs, who have intense, elaborate, and important experiences–understand the decision-making processes, and, for example, thresholds for decisions. You gotta keep working with them, and that requires, obviously, openness to all things.”

‘Yeah. They’re frustrated’

As McDonough spoke with The War Horse, he had just come from one of his quarterly breakfast meetings with the veterans service organizations. Did they beat him up?

“Yeah,” he says, “they’re frustrated. They’re frustrated about our notices to the caregivers who now have a right to appeal, that those notices could be more robust. [The notices] could give the veteran and his or her caregiver more transparency into why they were denied. I think that’s right. They’re frustrated on the fact that we need to recognize that we are bringing our personnel back in what we call a future of work. That also means that we’re bringing back into our buildings VFW, American Legion, DAV, Paralyzed Vets, Dub Dub P [Wounded Warrior Project] personnel.” (Veterans Service Organizations often have offices in VA buildings so they can help with benefits, care, and outreach.) “And they’d like us to be as clear with them as we are with our own workforce, because they’re there. I tell them all this all the time, which is that they’re the front door for so many of our vets to the VA, and so they say, ‘Well, then you should treat us like that.’ So we should have more clarity.”

In other words, the VSOs want to know what decisions are being made and why as they’re being made–and they want to know if there’s been progress on the issues the VSOs have highlighted.

The VSOs don’t disagree.

“The VA caregiver program has been a blessing to thousands of veterans and their family caregivers; however, systemic problems have plagued the program from the outset,” DAV’s Ilem says. “VA must revise regulations determining eligibility for seriously disabled veterans and implement a new appeals system that provides veterans and caregivers justice.”

Ilem allowed that there has been progress.

“Taking office in the middle of a pandemic was a challenge, and VA continues to perform admirably for the veterans it serves and in meeting its fourth mission to serve the nation as a whole during national emergencies,” she says. “The secretary has made some important and meaningful progress, such as the addition of new presumptive diseases for veterans exposed to particulate matter. There have also been important course corrections in plans he inherited, as was done with the new electronic health record following a strategic review last year.”

Ilem says VA’s “most pressing challenge” is, as it is for everyone else, responding to the Covid pandemic — but while making sure veterans get the rest of the benefits they earned. That includes making sure VA has the money to “recruit, hire, and retain” good employees.

DAV, as well as many of the other VSOs, have made toxic injuries — from burn pits, from polluted water, from Agent Orange, from anti-nerve agent pills and sarin gas — a top, if not the top, priority. (DAV’s Dan Clare was the first to leak, anonymously, the documents outlining the concerns with the Balad burn pit to a reporter back when he worked in military public affairs in 2008.)

“Veterans should never have to wait decades to receive recognition for injuries and illnesses that occurred while serving our nation in uniform,” Ilem says.

Mental health care and suicide prevention also top her list and require collaboration with other groups, she says.

She says she worries about the issues that don’t make the headlines: that the Asset and Infrastructure Review ensures VA has the capacity it needs, that IT systems across VA be modernized, that the new electronic health record system is successful. (It hasn’t been so far, instead being marked by delays, errors, and cost overruns.)

Still, her tone is hopeful.

“From our experience, Secretary McDonough has been open, accessible, and willing to have frank and honest conversations with DAV and other veterans service organizations,” she says. “We appreciate his willingness to share information with us, and, most importantly, listen to our concerns and recommendations about veterans’ benefits and health care services.”

Kerry Baker, veterans advocate and former Veterans Benefits Administration employee, also has concerns about the behind-the-news issues: He worries that toxic exposure at Fort McClellan will never be properly addressed, and he worries about what a new process to determine which health conditions can be automatically associated with service might look like. He believes the Veterans Appeals Improvement and Modernization Act of 2017 helps the segment of the population that chooses a quick appeal, but pushes those cases with errors — made by VA — in their claims to the back of the line, even as the backlog grows because of COVID and new presumptive conditions: “It goes against everything Congress and VA touted the new law was for,” he says. And he says the “fundamentals” of rating a veteran’s injury or illness have been lost in a culture of finding ways to tell the veteran no, rather than giving them the “benefit of the doubt,” as the law says they must do.

“People [in and out of VA] like to lean on the ‘complexity’ of exposure cases as an excuse,” Baker says, referring to the difficulty in directly linking exposure to disease after a veteran has been exposed to particulate matter or carcinogens. “Looking back, I am even guilty of it. But the vast majority of mistakes in exposure cases are the simple version — mistakes in the fundamentals of rating. In that light, the ‘biggest’ problems are actually the easiest to fix — the low-hanging fruit.”

Baker wrote the first training letter about burn pit exposure while he was at VA, and he sees many of the benefits problems as training issues.

At a mid-January press conference, McDonough told reporters the backlog stood at about 70,000 claims pre-Covid, but since then the crisis and the addition of several new presumptive conditions added 174,000 claims in addition to the usual flow of new cases coming in. The backlog stands at about 260,000 cases right now, but McDonough said they’re hiring more than 2,000 claims processors, paying overtime, and making progress on scanning veterans’ records at the National Archives so they’re easier to access. At the press conference, Rob Reynolds, acting undersecretary of VA’s Office of Automated Benefit Delivery, said a new pilot looking at service-related hypertension would automate the system to get rid of unnecessary medical exams and reduce the back-and-forth of paperwork. If the veteran has enough medical evidence in their file, the rating system will fill in the disability rating and create a proposed rating system. If there’s not enough information, the system will request a medical exam.

“I am hopeful in the long run,” Baker says, “but it’s mostly more of the same in the short term.”

‘We’re just trying to put everything out there’

It’s a lot: the lack of clarity. The decades-long issues. The stakeholders coming from a dozen directions. The need to keep up morale.

“It is a lot,” McDonough acknowledges.

But in his mind, Baker’s right: It’s a matter of simplicity. Part of the problem is communication, McDonough says, hence the press conferences, breakfasts, blogs, and newsletters. The press, the veterans service organizations, the veterans and their families, and Congress all need to know what’s up.

“So we’re just trying to put everything out there,” he says. “And my theory is, the more people see the information, the more confidence they can have that the decision itself is actually — whether it’s a good or bad decision — it’s at least informed by the best available information.”

After the fiasco of the investigation into the House Veterans Affairs Committee staffer who reported assault, McDonough brought in women to help him rebuild. Kayla Williams, who had been appointed during the Obama administration as director of the Center for Women Veterans, is back as the assistant secretary of the Office of Public and Intergovernmental Affairs. She has pushed the issue of monthly press conferences and press access, and, as a veteran herself, has long been a proponent of VA facilities that reflect all of their clientele — and not just the traditional square-jawed, straight, white male image that appeared in old movies. (Williams is a War Horse fellow and past contributor.)

“I think it’s also not a mistake that several of our senior communicators are women veterans,” McDonough says.

The Veterans Experience Office, under John Boerstler, continues the work it began under Obama to map the veteran’s experience, look for hiccups in the system through human-centered design, and set up events to simply listen to veterans. When VA decided which Electronic Health Record portal to use, McDonough had Boerstler’s team ask the veterans which one they prefer.

“I love John Boerstler,” McDonough says. “I think he’s maybe the single most creative policymaker I know. And on one level, he’s not even that creative, because what he keeps just saying is, ‘We need to listen to vets.’”

Overall, he says he feels like he has a handle on it.

“I feel quite liberated because what we do here is not classified,” he says. “It’s hard. But it’s no secret. And we shouldn’t treat it as if it is.”

‘It’s the law of the land’

The Veterans Access, Choice, and Accountability Act started as a way to expand health care services to veterans who had to wait too long for services, or who lived long distances from VA facilities. Trump expanded it with the MISSION Act, saying he wanted veterans to be able to choose private care, if they preferred it.

“I think there are some people who see that as an effort to sap resources away from VA,” McDonough says. “The way I see the MISSION Act is it’s the law of the land. It gives us really important tools. It, I think, is particularly meaningful and important for rural vets.”

But rural health facilities of all kinds are struggling right now to meet the needs of their local populations, and McDonough sees VA as part of a solution to address that need. Because of the COVID pandemic, VA created a two-year training program to “grow the health care workforce in rural communities.” Rather than allow the MISSION Act to show VA health care isn’t necessary, the administration turned the story on its head by using VA to try to improve community access for everybody.

“If we can then crosswalk our in-care — in-system care — with community-provided care, and maintain our central role as the integrator of that veterans’ care, then we will kind of get to the next level as not only the premier provider of health care to veterans, but the central pillar in the overall health care system in the country. And so that’s what the ‘tool’ of the MISSION Act can allow us to do.”

VA also geared up to provide vaccines for all veterans — including those not in VA’s system, veterans’ spouses, and caregivers — and expanded telehealth care to keep patients and providers safe during routine exams or prescription updates, as well as to provide care to veterans who are less likely to show up at an office, such as veterans without homes.

In mid-January, McDonough told reporters Omicron had hit VA hard: Admissions hit an all-time high of more than 300 a day in early January, and 15,000 health care employees stayed home after a Covid-positive test. He said VA had stepped up, and veterans should know care is still available.

But it’s still a challenge: A November inewsource investigation found that, even after doctors sent veterans to outside care for treatment, administrators refused those orders to save money and keep veterans within the VA system. The problem began under Trump and continued under Biden.

“If we’re competing with others in the system, and we’re trying to make a case to the veteran, the best way to make the case for veterans to stay in our care is to get the veteran in for timely access to care,” he says. “So under 20 days for primary care, 28 days for specialty care. And if we can’t meet those, that’s on us. That’s not on the MISSION Act.”

‘I think the interview with Jon Stewart was fine’

McDonough recently appeared on “The Problem with Jon Stewart,” where Stewart, a huge burn pit-benefits proponent, pushed McDonough for not acting quickly enough to get veterans help.

“You know, the interview with Jon Stewart, I think, was fine,” he says. “I think it’s good. I think the really important part of it is he’s raising awareness among so many people in the population about something that is so critically important to a smaller part of the population who really feel left behind. And so I think that’s an absolutely important service. And I was really — I’m really glad I did it.”

He alluded to an important change during the interview, but it was probably too nuanced for that particular moment: He’s working to change the presumptive-status decision-making process. It’s mired in bureaucracy, law, and Congress. And that’s not so different from other government agencies, so there’s a Biden directive to do things differently across the board.

“I think the best way I can answer the question is to say, how are we structuring the decision-making process so as to force decisions?” he says. “So often, what happens in government, and frankly, everywhere, is the avoidance of decision-making, rather than the forcing of decisions and then defending your decisions.”

So, they talk — all of the agencies — and they hold each other accountable. But everybody also knows what everybody else needs, he says, including the president.

“We’re actually sitting around the table with the Department of Labor who, through OSHA, has access to a lot of stuff about toxic exposure. Department of Defense, obviously, HHS, which is the parent agency for, for example, the National Institutes for Cancer. So we then not only are accountable to the president for the decision-making, we also have a wider range of information to inform the decision-making. We’re not just taking it from ourselves or from the national academies. We’re actually getting it from many, many sources.”

In the meantime, he says Biden has pledged to increase research and development on toxic injuries. That plays out in trying to figure out how to diagnose constrictive bronchiolitis in a way other than by cutting open someone’s chest for a biopsy. (Veterans’ benefits have often been denied for constrictive bronchiolitis because it doesn’t show up on X-rays or scans.) Biden has also pushed him on brain cancer, he says. Biden’s son Beau died of brain cancer after serving in Iraq, and Biden has said he believes there may be a correlation.

“The president said, ‘I want an answer early in the new year on rare respiratory cancers,’” McDonough says. “He’s also pressed me hard on brain cancers. And veterans have pressed really hard on constrictive bronchiolitis. And so we say, ‘Not only are we looking at it, and here’s how we’re looking at it, here’s who we’re responsive to look at it. But here’s a timeline on which you can expect a decision.’”

He expects a decision about rare respiratory disorders connected to burn pit exposure in the “early part of the year,” he told reporters Jan. 18.

The internal decision-making process has also changed at VA, McDonough says: Once a quarter, he meets with his executive board, and he comes out of those meetings with decisions made. Then he announces them — at the breakfasts, at the press conferences, at Congressional hearings.

“So we built the structure to force the decisions based on the fact that the president’s person is in the chair,” he says. “That gives us additional information. We’re developing new tools to figure out how to diagnose these illnesses. We are getting additional information to inform the decision-making. We’re putting ourselves on the hook. Well, the president puts us on the hook.”

Then, as with the decision to offer gender confirmation surgery, McDonough defends it.

He used the caregiver situation as an example: After years of service by military spouses and other family members as unofficial caregivers, VA realized it could probably save money by simply paying those spouses or moms or dads to be full-time caregivers. But as more service members came back from war with head injuries or chronic PTS, the program became more costly. Suddenly, people who either had been acting as caregivers for years or were newly caring for veterans with severe disabilities were booted from or not allowed into the program. Now, VA is pushing through a new congressionally mandated appeals process to try to fix that. But a big part of the problem, McDonough says, is that the three internal agencies don’t talk to each other — they don’t even necessarily know what their colleagues do, let alone the decisions that have already been made on a particular case. And, he says, everyone involved should better understand the consequences of war, the daily care of someone dealing with a traumatic brain injury, and how it feels to live with PTSD.

“We should know what VBA knows about the veteran before VHA makes that decision,” McDonough says. “There’s a lot of work we can do to make the decisions more round, more inclusive. … But until then, we also have to be open to downstream consequences in recognizing that they’re connected to service. And we have to hear that, learn from that. Listen to the vets, listen to survivors, caregivers, to make sure that we’re learning, because I think we learn every time we go to war that this is a very impactful experience.”

As troops stand ready to go to defend Ukraine, those lessons must be on decision-makers’ minds as they talk about VA’s ever-expanding budget.

‘That’s not a good talking point’

McDonough says there hasn’t “really” been any progress on the electronic health record situation. In 2018, Wilkie announced Spokane would be the testing ground for the 20-year battle to integrate Defense Department and VA health records. The result was a disaster, as reported by The Spokesman-Review, with long delays in care and staff threatening to quit.

“We’ve kind of been in a moment of suspended animation really trying to learn the lessons of Spokane,” McDonough says. “But we just had, I think, two good weeks of explaining to policymakers, talking to our workforce, talking to the press, about our plan for next steps. A big part of that is now having gotten people into the right positions.”

The situation served as an example of groups not speaking to each other, and then basically sitting on the fence rather than taking responsibility for a decision, he says. In March, with better plans and better decisions in place — he expects — they’ll try again at the Columbus, Ohio, site. The right people are in place, with Terry Adirim heading it up, he says.

Is everyone playing well together on the new plans?

“So far,” he says, “but it’s early. This is a little bit like an earlier question: This is a trust-but-verify one. We’ll stay on top of that.”

McDonough spent his first year at VA working with a budget from the previous administration — and spending surpassed that budget. According to data he had from October, VA had spent just over $2 billion in the community, he says, and they know they need to get a handle on it. Part of that increase probably came as veterans returned to hospitals for care they’d put off during the pandemic, he says, as well as others who learned they were eligible for care when they went in for COVID vaccinations. (By mid-January, VA had vaccinated 4 million veterans, 80,000 spouses, and 28,000 caregivers, McDonough told reporters.)

But a large portion of the money spent on care remains, as it does in the civilian health care system, for people who use the emergency room. This happens either rather than using lower-cost urgent care facilities or because they haven’t received the treatment they needed — blood pressure medications, insulin, counseling about diet, mental health treatment — and their health situation has developed into a crisis.

“As I’ve said, a million times, I’ll make every decision based on increased access, improved outcomes,” he says. “And when we do that, we’re gonna see costs flattened, and we’re gonna see satisfaction increase.”

At the same time, the president tasked him with expanding outreach — which isn’t cheap.

“I say all the time, when the president has told me to be an advocate for veterans, he doesn’t mean some, he means to be an advocate for all veterans,” McDonough says.

That’s how the gender-confirmation-surgery decision came about: He reached out to the VHA Governing Board to get a recommendation for the surgery, which hadn’t been allowed at VA for 20 years. He learned that “veterans suffering gender dysphoria who are appropriately treated see dramatic improvements in mental health, dramatic reductions in suicide.” So, he said, “That’s what we should do.” Recently, VA also added a “+” at the end of the name of VA’s LGBTQ program to ensure everyone feels included. And VA announced in January that health records now display gender identity.

McDonough’s also working on outreach and care for women, he says. He cited The War Horse’s story about rising rates of breast cancer in women veterans and said VA is “getting more aggressive about gender-specific care.”

“You know, one of our talking points is we have 69 facilities where you can get a mammogram [in the] United States, which is a fucking pittance,” he says. “That’s not a good talking point. That’s a bad talking point. So, we’re dramatically increasing access to technology, like mammography. But we’re nowhere near where we need to be.”

McDonough has considered VA’s history, those years of denying problems and benefits, of telling Desert Storm veterans their symptoms were in their heads or Vietnam veterans that exfoliants were safe or treating atomic veterans as if their health concerns could not be addressed because they were top secret. What might have happened if VA had simply cared for those veterans? Could it have saved the government money as their health concerns grew chronic? It’s a big question that can’t be answered without considerable research.

“But that concept is infusing our work,” he says, “to say, ‘How do we do better at identifying something early before it manifests as crisis?’”

There’s more than that: There’s addressing mental health before it becomes deadly with mind-body work. There’s pushing for gun locks on firearms so veterans don’t have instant access at critical moments. He knows, after working with Obama on the Affordable Care Act, that preventive care saves health systems money.

“And so at the end of the day, my guess is, those kinds of steps are going to be helpful to the overall budget picture, but they surely are commonsensical,” he says. “And so if had we done a better job of recognizing? Well, look, I mean, I wish we didn’t use burn pits. That’d be the best thing.”

His dream? To address suicide and mental health in a significant way, as well as to fix the backlog.

“I think that the most important thing is to deliver on our core course requirements,” he says. “And core course requirements are delivery of world-class health care at VHA, and delivery of timely benefits at NCA and VBA. So obviously, in the first one, that includes suicide [prevention] and access to mental health [care], and the second one includes the backlog. And I have dreams about specific advancements in both of those places.”

But he wants more than just downward trends: He wants an “intensification of progress.”

“That’s what I’m looking for, is the game-changers,” he says. “And that will come from innovation. That will come from trusting one another. That will come from shaking off this crisis of confidence.”

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Veterans are able to experience greater freedom to live fuller lives as part of the VA Medical Foster Home program.

Samuel Maneely is 98 years old and Jacob Tingle is 89 years old. They both live with Sharon Smack-Dixon, who opened her door up to Veterans who can no longer live alone.

“It’s like family,” said Maneely, a World War II Veteran. “We do all kinds of stuff—watch TV, play checkers. We get along.”

“I love that woman,” said Tingle, a Korean War Veteran. “She’s like a sister. I’m very happy here.”

For Smack-Dixon, she said she enjoys the two Veterans because they act as grandfathers to her grandchildren.

“I decided to become a foster home provider because I had my father who I had to take care of and he was a Vet,” she said.

About the program

There are over 1,000 Veterans in the program and 700 Caregivers in 42 states.

Medical Foster Homes are private homes in which a trained caregiver provides services to a few individuals. Some, but not all, residents are Veterans. VA inspects and approves all Medical Foster Homes.

A Medical Foster Home can serve as an alternative to a nursing home. It may be appropriate for Veterans who require nursing home care but prefer a non-institutional setting with fewer residents.

Medical Foster Homes are private residences where the caregiver and relief caregivers provide care and supervision 24 hours a day, 7 days a week. This caregiver can help the Veteran carry out activities of daily living, such as bathing and getting dressed. VA ensures that the caregiver receives VA planned care training. While living in a Medical Foster Home, Veterans receive Home Based Primary Care.

For a list of VA Medical Centers with Medical Foster Home programs, visit https://www.va.gov/GERIATRICS/docs/VA_Medical_Foster_Home_Locations.pdf. This list includes the VA Medical Centers currently operating a Medical Foster Home program. However, many facilities are in various stages of development of their own programs. Please reach out to your VA social worker to ask about when a Medical Foster Home will be available at a local facility.

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Vietnam War-era Veterans who served in Thailand say they’re still fighting.

Veterans who served in Thailand have long contended they face a higher bar in winning Veterans Administration (VA) disability benefits claims, having to clearly demonstrate they were exposed to Agent Orange or other harmful herbicides while their fellow Veterans enjoy a presumption that they were exposed.

Several bills in Congress purport to take aim at the problem. Among them: The Veterans Agent Orange Exposure Equity Act, the Cost of War Act, and others, including the Fairly Assessing Service-related Exposure Residual (FASTER) Presumptions Act, also dubbed the “FASTER” Act.

A Maryland Democrat, David Trone, a member of the House Veterans Affairs Committee, has introduced the latter piece of legislation.

“We’re going to try to right a wrong,” Trone said.

‘We’re old news to them.’

As some Thailand Veterans see it, the VA places an undue burden of proof on them to demonstrate they were harmed by Agent Orange, in some cases asking for photographs or other evidence of physical proximity to harmful herbicides.

It’s not a burden shared by Veterans who served in Vietnam or in the Navy.

“If you set foot on a land mass (in Vietnam), you’re entitled to a presumption” that you have been exposed to herbicides, Rhode Island attorney Robert Chisholm said in an interview. That presumption has been expanded to blue-water Navy Veterans.

But not to Veterans in Thailand — at least, not yet.

In October 2020, the VA denied Xenia resident and Thailand Veteran Paul Skinner compensation for what Skinner believed was Agent Orange exposure, with the VA informing Skinner in a letter: “Your personnel records still fail to show that during your duties you were exposed to Agent Orange or tactical herbicides while performing daily duty assignments at Udom (Royal Thai Air Force Base).”

Skinner acknowledges that he can get health care from the VA. But he sought (and seeks) compensation for pain and suffering. Skinner, who has fought prostate cancer since 2018, has gone through 44 treatments of radiation therapy. He has to apply and use a catheter twice a day, something he expects to do for the rest of his life.

“We’re old news to them,” Skinner said of the VA.

Arnie Harmon, a Columbus-area Veteran who served in Thailand, filed for compensation or a monthly stipend some 15 years ago at the urging of one of his physicians. “I’m spending out of pocket about $6,000 to $6,500 a year in medications,” he said.

“You submit a claim,” Harmon said. “They (the VA) will grant it, (or) they’ll grant it partially, (or) they’ll deny it, which is probably about 80 to 90% of the Thailand Veterans, they have been denied. Some have won on appeal.”

This letter rejecting Skinner’s claim cited an Aug. 2015 memo from the Air Force Historical Research Agency (AFHRA), a memo that Veteran Robert McHenry, a friend to Skinner and others, fought for years.

Centerville resident McHenry died in July 2021 at the age of 74. McHenry worked for years to correct what he argued was an error in that memo, which held there was no evidence of tactical herbicides having been used at American bases in Thailand.

The AFHRA memo said that although use of commercial herbicides is documented, the Air Force archivists found no mention of the transportation, payment for or use of any tactical herbicide to control vegetation on Air Force installations in Thailand.

“Bob has been fighting this letter since it came out,” Skinner said.

“They used that letter repeatedly to deny claims,” Mary Flodder, McHenry’s widow, said in an interview.

Skinner said the denial was frustrating. But he trusted McHenry to make the historical case for him and Veterans like him.

“He (McHenry) was a walking encyclopedia of information,” Skinner said. “He did so much research on this letter (the Aug. 2015 memo).”

“These men are now in many cases in their 80s,” Trone said. “They deserve quick adjudication for their claim … and we cannot put the burden on the Veterans who served their country.”

Trone’s bill would force these to be adjudicated this quicker, presuming that they were exposed to harmful herbicides.

But the prospects for those bills is uncertain at this point.

In the ‘spray zone’

“Everyone that was on the bases would have been in the spray zone” for the herbicides, Flodder said. “Bob was trying to get that letter rescinded at the time he died.”

Typically, the VA looks for evidence of duty near base perimeters or fence lines to establish herbicide exposure. Often fence lines were sprayed to kill vegetation that may have hid the presence of enemy soldiers.

In an interview, Skinner recalled that he was an aircraft mechanic on F4 Phantom jets while serving in Thailand. He said he worked in areas close to base fencelines and perimeters, sometimes chaining down jets to run the engines, “which would actually kick up dust and dirt everywhere around the aircraft.”

His living quarters were also close to a base perimeter, he recalled. The herbicides were in the very air, he believes.

“I guess the VA doesn’t believe the wind blows,” Skinner said.

“They (the VA) don’t give you a definition of what the perimeter is,” Harmon said. “Is it two feet from the perimeter? Or is it 500 feet? Because all the perimeters were sprayed with various types of herbicides with dioxin in it. Agent Orange is just a euphemism for many different types of herbicides. But they were all sprayed.”

A spokeswoman for the Department of Veterans Affairs declined an interview but offered to answer questions in writing.

“Unlike Veterans who served in Vietnam and certain areas of Korea, Veterans who served in Thailand are not entitled by law to a presumption of exposure to tactical herbicides,” the spokeswoman said. “Lack of a presumption of herbicide exposure does not prevent Veterans from demonstrating through competent evidence that they were exposed to herbicidal agents and that such exposure is sufficiently related to a current disability to warrant disability compensation.”

Currently, Skinner hopes to make a case before a VA judge in perhaps a year, maybe longer.

A spokeswoman for the Air Force said neither the author of the AFHRA memo nor anyone else was available for an interview.

‘These bills have a chance’

A solution by Congress may be the best approach, some attorneys and Veterans advocates say.

“My sense is these bills have a chance, but I just don’t know how good a chance,” attorney Chisholm said.

Sen. Rob Portman is listed as a co-sponsor of Senate Bill 657, which would modify the presumption of a service connection for Veterans who were exposed to herbicides while serving in Thailand. The bill was last referred to the Subcommittee on Disability Assistance and Memorial Affairs in June.

A VA spokeswoman said If enacted, S.657 would expand universal eligibility for Veterans who served in Thailand.

Sen. Sherrod Brown supports the Thailand Veterans Toxic Exposure Act, a version of which was included in the Senate Veterans’ Affairs Committee’s toxic exposure bill reported out of committee in May.

“Time is running out for these Veterans,” Brown said in an email. “I will continue the fight to get benefits for all Veterans who were exposed to Agent Orange — and other toxic chemicals — regardless of where they served.”

Questions sent to the offices of Portman and U.S. Rep. Mike Turner, R-Dayton. Turner has supported similar legislation in the past.

Harmon said his sense is that once attorneys are involved, claims from Veterans who served in Thailand can be settled in as quickly as six months.

Chisholm said he and like-minded attorneys representing Veterans who served in Thailand are winning these cases one at a time, but with detailed evidence, detailed arguments, detailed affidavits.

Poway, Calif. attorney Amanda Mineer recalled working on one case in which she and her team had to introduce into evidence a photo of a sailor taking a photographic selfie of himself on a ship as that ship crossed the equator, with barrels of Agent Orange nearby, visible in the photo.

The photo helped her win the case.

“That’s what we do; we get creative,” Mineer said. “That’s our job.”

“It’s still essentially a case-by-case basis,” Chisholm said. “You have to prove it.”

But proving it isn’t always possible, others say.

“Let’s be real, this was 60 years ago,” Trone said.

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LOS ANGELES – A West Los Angeles pharmacist was sentenced today to 30 months in federal prison for orchestrating a scheme that fraudulently obtained millions of dollars for compounded drugs in a scheme that paid illegal kickbacks for patient referrals and fraudulently paid patients’ copayments.

Navid Vahedi, 42, of Brentwood, was sentenced by United States District Judge Christina A. Snyder. Vahedi and his West Los Angeles-based company, Fusion Rx Compounding Pharmacy, pleaded guilty in February 2021 to one count of conspiracy to commit health care fraud and payment of illegal remunerations.

On January 18, Judge Snyder sentenced Fusion Rx Compounding Pharmacy to five years of probation. She has ordered Vahedi and his company to jointly pay $4,400,525 in restitution.

Fusion Rx was a provider of compounded drugs, which are tailor-made products doctors may prescribe when FDA-approved alternatives do not meet the health needs of patients. Vahedi, a licensed pharmacist, and Fusion Rx routed millions of dollars in kickback payments through the businesses of two marketers to steer prescriptions for compounded drugs to Fusion Rx.

As part of the scheme, Vahedi and the two marketers provided physicians with preprinted prescription script pads that offered “check-the-box” options on the form to maximize the amount of insurance reimbursement for the compounded drugs. From May 2014 to at least February 2016, Fusion Rx received approximately $14 million in reimbursements on its claims for compounded drug prescriptions.

As part of its contracts with various insurance networks, Fusion Rx was obligated to collect copayments from patients. Because the copayments might discourage patients from requesting expensive and potentially unnecessary compounded drug prescriptions, Fusion Rx did not collect copayments with any regularity and, in other instances, it provided gift cards to patients to offset the amount of the copayments, according to court documents.

After an audit raised concerns that Fusion Rx’s failure to collect copayments would be discovered, Vahedi directed Fusion Rx funds to be used to purchase American Express gift cards, which were then used to make copayments for certain prescriptions without the patients’ knowledge. Fusion Rx then submitted claims on these prescriptions to various insurance providers, falsely representing that patients had paid the required copayments.

“As a pharmacist offering compounded medications, [Vahedi] had a real opportunity to use his skills to help patients in need, individuals whose unique health challenges made it impossible for them to depend on the FDA-approved medications others rely on,” prosecutors wrote in a sentencing memorandum. “Instead, defendant converted his pharmacy into an assembly line for his own enrichment.”

The two marketers involved in the scheme – Joshua Pearson, 42, of St. George, Utah, and Joseph Kieffer, 41, of West Los Angeles – previously pleaded guilty in this case. Judge Snyder sentenced Kieffer to six months in federal prison and ordered him to pay $1.25 million in restitution. Pearson was sentenced to three years of probation.

The Defense Criminal Investigative Service, the FBI, the Amtrak Office of Inspector General, the Office of Personnel Management’s Office of Inspector General, and the Office of Inspector General for the United States Department of Health and Human Services investigated this matter.

Assistant United States Attorneys Alexander B. Schwab of the Major Frauds Section and Jonathan S. Galatzan of the Asset Forfeiture Section prosecuted this case.

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Democrats hope their new health care, tax and climate law begins to rein in soaring prescription drug prices.

One of its most touted provisions allows Medicare, America’s health insurance program for seniors, to negotiate some prescription drug prices for the first time, with some calling it “game-changing” and a significant victory over the pharmaceutical industry. Drug manufacturers had stubbornly opposed any governmental regulation of drug prices for decades and are likely to challenge the measure in court.

As a scholar who has published extensively on the politics of health policy, I’m skeptical that giving Medicare the ability to negotiate prices on a handful of drugs will be as transformative as the law’s backers hope. While a good step, it is unlikely to make a significant difference in how much seniors pay overall for medicine.

Fortunately, there are several other provisions in the law that will do much more to meaningfully help seniors struggling with the high cost of prescription drugs.

Why US drug prices are so high

Pharmaceutical innovation over the past few decades has been tremendous. The quick response to the COVID-19 pandemic in terms of vaccine development and treatments perfectly exemplifies the incredible benefits that drug developers have brought to the world.

Yet these developments have come at a high price, particularly in the United States, where each person spends more than US$1,100 a year on drugs – up from $831 in 2013. Indeed, Americans are paying substantially more than residents of similar countries like Germany, the U.K. and Australia – who pay $825, $285 and $434 per person each year, respectively.

People who need specific high-priced drugs are even more adversely affected.

Dulera, an asthma drug, costs 50 times more in the U.S. than the international average. Januvia, for diabetes, and Combigan, a glaucoma drug, cost about 10 times more. Americans shell out, on average, $98.70 for a vial of insulin, compared with the $6.94 Australians pay.

These costs impose a big burden on Americans – 1 in 5 of whom skip medications because of the cost. Seniors are particularly affected by these problems.

The reasons for high prices are varied, including the overall complexity of the U.S. health care system and the lack of transparency in the drug supply chain. But as I noted in a 2019 article in The Conversation, the biggest reason Americans pay so much more than people do elsewhere is simple: Pharmaceutical companies face no limits setting prices.

Changing the game – a little

The new law, known as the Inflation Reduction Act and signed into law on Aug. 16, 2022, seeks to change that.

The main mechanism to do it is by allowing Medicare to negotiate prices for some of the most expensive drugs. The act gives Medicare the ability to negotiate with drugmakers for 10 drugs starting in 2026 and 20 by 2029.

The law specifies that the medications Medicare is supposed to select must account for most of its spending on drugs and be name brands with no generic equivalents. Research has found that a relatively small number of drugs are responsible for most spending.

Importantly, pharmaceutical companies may face civil penalties and additional taxes on drug sales if they do not comply with the requirements to establish a “maximum fair price” as laid out in the law.

The provision is expected to save the U.S. government about $102 billion by 2031 by allowing it to pay less on prescription drugs for Americans on Medicare – currently 63 million people. The annual savings amount to about 5% of what Medicare currently spends on drugs.

There’s also a separate provision that requires pharmaceutical companies, under certain conditions, to provide Medicare with rebates if drug prices outpace inflation. That measure takes effect this year and is expected to yield $71 billion in savings over a decade.

While the government savings are meaningful, I believe seniors themselves are likely to see only a minor drop in costs as a result of this provision, mainly through slightly reduced premiums and lower out-of-pocket costs.

Where the real savings are

The provisions that will make a much bigger difference for seniors lie elsewhere.

Importantly, the new law limits seniors’ out-of-pocket expenses for prescription drugs to no more than $2,000 annually. Previously, there were some restrictions but no limit. This will directly help 1.4 million seniors who exceeded the $2,000 threshold in 2020.

The law also limits how fast premiums for Medicare Part D, which provides premium-based prescription drug insurance, can rise over the next few years and implements a number of other adjustments.

It also extends the Medicare Part D low-income subsidy to 400,000 seniors who previously earned too much to qualify. This program helps people pay for premiums, deductible and copays and has been valued at $5,100 a year.

The legislation also limits the cost of insulin to no more than $35 per month for Medicare recipients only. This amounts to more than $1 billion in annual savings for seniors. Almost 16 million American seniors have diabetes and are likely to need insulin at some point in their lives.

Lastly, it also eliminates out-of-pocket costs for seniors for vaccines – a move that would have saved money for 4.1 million people in 2020.

Broader impact

There are real benefits in the bill President Biden signed into law. The government will save by negotiating prices. Seniors will save through the insulin cap and other provisions.

But I don’t believe Medicare’s ability to negotiate prices will be a game-changing reform.

Besides affecting prices paid by only a slice of Americans, we do not know how aggressively the federal government will seek savings. This particularly applies to any future administration headed up by a Republican president.

The pharmaceutical industry may still manage to limit the impact of price negotiations, since it will be four years before the changes take effect. The industry has a history of skillfully exploiting loopholes and a vast lobbying apparatus to put into that effort.

As for Americans who aren’t covered under Medicare, drug prices may actually go up. That’s because, if pharmaceutical companies do end up reducing drug prices for seniors, they may shift those costs to everyone else to make up for those lost profits.

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One way to stand up for former service personnel is to advocate for more affordable housing, says BU researcher

The signs dot highway bridges and town halls, celebrating the return of armed services personnel from dangerous overseas missions. “Welcome Home,” they proudly, joyously, declare. But for many veterans—carrying the visible and invisible scars of battle, more vulnerable to suicide, physical and mental illness, and substance use disorders—the message rings hollow: they might not even have a stable home to return to. Ex-service members have long been at greater risk of homelessness than the general population.

Thomas Byrne, a Boston University School of Social Work associate professor, is an expert on homelessness, and among the researchers studying why veterans are more likely to land in shelters—and how to better help them. He says that a lack of affordable housing can make it especially tough for former service members to find a stable home, and that those who want to help them should advocate for more economical options.

Byrne has studied housing insecurity in rural areas, the effectiveness of Department of Veterans Affairs (VA) housing programs, and the community and structural drivers of homelessness, such as income inequality and housing affordability. His latest project is a major assessment of Supportive Services for Veteran Families, a program that provides grants to community organizations helping those at high risk of homelessness. One focus of the research is an initiative giving veterans flexible temporary financial assistance that they can use on anything from security deposits to utility bills.

“We’ve found it’s associated with better housing and health outcomes,” says Byrne, who is also an investigator at the VA’s National Center on Homelessness among Veterans and with the Center for Healthcare Organization & Implementation Research at the VA Bedford Healthcare System. “We’re also nearly there on a study that’s comparing participation in this program to a group of veterans who don’t get it, so we can as rigorously as possible estimate its impact.”

Byrne first became involved with the VA as a graduate researcher—but the work has taken on additional meaning in recent years.

“I have members of my immediate family who are on active duty,” says Byrne, “including one of my sisters and brother-in-law. I serendipitously became involved with the VA, but it also has a personal salience for me.”

The Brink spoke with Byrne about why veterans might be at greater risk of homelessness, the stigma faced by those dealing with housing insecurity, and what we can all do to help.

The Brink: How big of an issue is homelessness among veterans? I’ve read that while veterans have historically been at greater risk of homelessness, the situation is improving.

Byrne: The research, including some studies that I’ve been a part of, does show that veterans do face an elevated risk of homelessness relative to the general population. Folks may think that veterans face an elevated risk due to stressors they might experience while they’re on active duty, combat experiences. When you look specifically within members of the military, combat exposure and PTSD are associated with higher risk of homelessness. And when we are talking about the most recent generations who served in Iraq and Afghanistan, there is some evidence that the dynamics of their homelessness is different, in that they appear to become homeless more quickly after exiting the military as compared to older veterans.

But, broadly speaking, it’s not entirely clear why veterans, as a group, have a higher risk than the civilian population. One possibility is that it has to do with the fact that military veterans are not necessarily representative of the general US population. There’s some evidence that you see the elevated risk of homelessness for veterans first show up when the military switched to an all-volunteer force. What you get is not necessarily a broad-based sample of the population entering the military. You have folks who have socioeconomic characteristics, and maybe life experiences, that may have put them at an elevated risk of homelessness even prior to their military service. And so they remain at an elevated risk once they discharge. I think that’s certainly a plausible theory.

Veterans experiencing homelessness are mostly male, but are there other things, apart from service, that they have in common?

Military veterans are a heterogeneous group with respect to premilitary, military, and post-military risk factors. There’s been some research that’s tried to look explicitly at those three things. A lot of the risk factors for homelessness in the general population—adverse life experiences, lack of economic resources—also apply to members of the military. For premilitary risk factors, adverse childhood experiences can contribute; during military service, traumatic experiences—whether it’s combat exposure, military sexual trauma; and then post-military factors—job loss, financial difficulties, dissolution of relationships. One of my colleagues did a study looking at risk factors among military veterans who served in the post-9/11 era, and one of the strongest was military pay grade, which is a proxy for socioeconomic status.

How do you define homelessness, because different groups categorize it in different ways?

When we’re talking about homelessness in the United States, there is a definition that is shared by the Department of Veterans Affairs and by the Department of Housing and Urban Development. And it is basically people who are living in emergency shelters or transitional housing, residential programs specifically meant for people experiencing homelessness, or people who are unsheltered—literally living on the streets or in places not meant for human habitation. When we’re talking about the number of veterans experiencing homelessness, it doesn’t count people who might be doubled up, or couch surfing, who might be in housing arrangements that are less than ideal or unstable in some way.

For some context, on a given night, there are around 37,000 veterans experiencing homelessness across the United States, and that’s a number that’s decreased by about 50 percent since 2009. Homelessness is a dynamic phenomenon: most folks who are homeless only experience homelessness for a fairly short period of time, and so there’s a lot of turnover in the population. The big reductions in homelessness among veterans over the past 10 to 12 years has a lot to do with the investments that the Department of Veterans Affairs has made in housing programs.

There’s still a lot of stigma around homelessness. Can you humanize it for us?

In some ways, the stigma of homelessness is an extension of the stigma that surrounds poverty in this country more broadly. Some of that is just deeply rooted in what we—broadly speaking, as an American society—value in individualism and self-reliance. We see poverty and homelessness as moral failings of individuals, when in reality there’s a lot of evidence, including work that I’ve done, that links homelessness in the aggregate most strongly to housing market conditions, the lack of affordable housing. It’s often the product of structural factors that mean we’re going to have some amount of homelessness, and then individual vulnerabilities that place people at a higher risk. There’s a lot of stigma, but there ought not be. For most veterans and people who are experiencing homelessness, it’s a really temporary phenomenon. It’s not something that people fall into and never escape from—it’s a housing crisis that people experience. More often than not, if people get some assistance to resolve that housing crisis, they’re likely to remain stably housed thereafter.

I think there’s less stigma when we’re talking about military veterans specifically, because of the social status that they hold in society. They’re a group of folks whom we as a society and our political leaders have decided merits special attention, and that’s come in the form of big investments in housing programs specifically for veterans experiencing homelessness. There’s been a lot of success from those efforts. I think that goes to show what can happen when you destigmatize the issue of homelessness and focus on solutions that work to address the problem.

According to Pine Street Inn, “56 percent of all homeless veterans are African American or Hispanic.” It also seems the improvements you’ve talked about haven’t necessarily reached them evenly. What is causing those huge disparities?

It’s part and parcel of the same structural forces that underpin lots of inequities in our society. When we’re talking specifically about housing, you can bring into the conversation things like redlining and discrimination in rental markets that may have historically made it more difficult for people of color to access housing and to build wealth, which might buffer them in the instance of an economic shock. What holds true in the broader population likely holds true for military veterans, as well.

What’s one thing everyone reading this can do to help veterans and others experiencing homelessness?

Ultimately, what’s at the root of homelessness, both among veterans and more broadly, are the issues of affordable housing and housing affordability. Wherever it’s within your power, advocate for the expansion of housing for folks who are experiencing homelessness or just everyone in general.

Part of what motivates me to do this work is that I think having a safe, decent place to live is a really fundamental right, and prerequisite to having any kind of decent life. Everyone would want that for themselves and for their family members, so just think about it in those terms. If people want to get involved more specifically, there are certainly organizations that are working directly with veterans experiencing homelessness. There’s a number of them here, locally, in Boston and in Massachusetts that are doing really great work. There is also sometimes a gap where some funding sources can’t be used to pay for certain things that people might need to set up their apartment, for example, so there’s a real need for philanthropy to fill in and provide funds.

Lastly, what message or advice would you have for veterans—or families of veterans—reading this who are concerned about their housing status?

It’s not unusual for me to get emails directly from veterans who are experiencing homelessness. And there are two resources that I direct folks to. The first is the National Call Center for Homeless Veterans, a 24/7 hotline where trained staff work to connect veterans and others with VA and non-VA services. The phone number is 1-877-4AID-VET (1-877-424-3838). The second is Supportive Services for Veteran Families, a homelessness prevention and rapid rehousing program funded by the VA, but operated by community-based agencies. The VA’s website has a comprehensive list of providers throughout the country and their contact information.

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Andrew Langer was pretty sure his daughter was on the wrong website when she tried to apply for new credentials to access Tricare, the military health program, from her home near Fort Eustis, Virginia.

As part of the online validation process for the Defense Department's MHS Genesis electronic health records system, Langer's daughter was told she would need to furnish the last eight digits of a credit card and undergo a "soft" credit check to gain access.

Sensing something amiss, she called her parents.

"I'm normally so patient with my daughter but, quite honestly, I got very impatient because I thought this was phishing.... I was like, 'Get off there. This is not right -- you don't need a credit card,'" Langer said.

Turns out, she did, as does anyone who must enroll in MHS Genesis or wants a new DoD credential, known as a DS Logon, to access the military pay system or their medical records.

It appears that the new requirement went into effect DoD and Veterans Affairs-wide within the past five months. For some, like Langer, it is an unwelcome change.

"It's a very simple yet privacy-invading way of trying to do identity verification," Langer said during an interview with Military.com. "Career civil servants tend to make these decisions without any sort of regard to the greater public policy implications -- the privacy issues, the disparate impact on folks who are struggling -- the idea that someone in their health care may know they have credit issues or are struggling financially."

The DoD Self-Service Logon, or DS Logon, is a digital credential used by military personnel and beneficiaries to access pay records, health services and other DoD administrative applications.

Once reserved for DoD beneficiaries only, the credential is now the standard for veterans, allowing them to check on the status of their Department of Veterans Affairs disability claims, health benefits applications, and other VA-related services.

According to Navy Cmdr. Nicole Schwegman, a DoD spokeswoman, users who apply for a DS Logon remotely must have their identity authenticated. The soft credit check is one way to verify the user, she said.

"The [Remote Identity Proofing] service is provided by a 3rdparty vendor and uses a variety of techniques to verify an individual's identity which involves data obtained through a soft credit check," Schwegman said in an email to Military.com. "These 'soft credit checks' do not impact a person's credit score."

She added that DS Logon has performed soft credit checks on individuals for more than eight years, although she admitted that neither she nor any of the military personnel in her office were aware of the requirement until asked about it by Military.com.

Users may just be noticing the new requirement as the Defense Department adopts the new Oracle Cerner MHS Genesis electronic health record system department-wide. When patients apply to access the new program, they are asked to provide a photo of their driver's license or another approved identification card and a credit card or a loan document to verify their ID.

Schwegman said that those who object to the credit check can use a Common Access Card to obtain a DS Logon or, if they don't have a CAC, can go to a DoD ID card facility and get their identity verified in person.

"Use of the remote identity proofing service is not a requirement for DS Logon issuance, but for some it is the most convenient option available," Schwegman said.

Langer, who is chairman of the Institute for Regulatory Analysis and Engagement, a nonprofit organization focused on the federal regulations and the administrative state, doesn't think that DoD beneficiaries should trade privacy for convenience.

He has written to the Defense Health Agency and reached out to two members of Congress to get answers on the new requirement, trying to find out who made the decision, why, and whether the DoD went through the proper regulatory process to enact it.

"I find no reference to it anywhere," Langer said. "I've gone down the rabbit hole trying to figure out who is responsible. … My suspicion is that the justification they will lay out is because they are trying to do this across platforms for DoD dependents, VA, DoD employees. I guess they are trying to standardize it. It still doesn't justify why."

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Many Veterans are diagnosed with obstructive sleep apnea, and therefore—with an effective claim that includes the right evidence—should be eligible for a sleep apnea VA rating. Since this condition is nearly epidemic among Veterans, it’s important to learn what it takes to get a VA disability for sleep apnea, as well as how the condition may affect you.

What is sleep apnea?

Sleep apnea is a serious sleep disorder in which breathing is briefly and repeatedly interrupted during sleep. This can occur from ten times to hundreds of times per night. The constant interruption of breathing can lead to reduced sleep quality, short-term memory loss, irritability and even mood disorders, as well as major metabolic diseases such as diabetes and heart disease.

Sleep apnea often is thought of as a mild annoyance, but it is a significant condition that can lead to health issues ranging from hypertension, stroke and heart attack to depression, anxiety and headaches.

How do I know if I have sleep apnea?

Symptoms of obstructive sleep apnea include:

• Loud snoring
• Episodes where you stop breathing during sleep
• Gasping for air during sleep
• Awakening with a dry mouth
• Morning headache
• Daytime sleepiness (hypersomnia) or insomnia
• Lack of focus or difficulty concentrating
• Irritability or anger

If you experience many of these symptoms, we recommend seeing a doctor as soon as possible and seeking a diagnosis. If you meet the requirement of having a current diagnosis, you can obtain a service connection and VA rating for sleep apnea and receive disability benefits.

It’s likely your doctor will need to order a sleep study to determine if you have sleep apnea. A doctor’s diagnosis will be one of the keys to getting a sleep apnea VA rating.

Why do so many Veterans have sleep apnea?

Research shows a strong correlation between deployments and sleep disorders, and sleep apnea is extremely common among Veterans. The Office of the Inspector General found that 1.3 million Veterans enrolled in VA Healthcare have a sleep apnea diagnosis.

As a Veteran, you’re four times more likely than other Americans to develop sleep apnea. According to the VA, 1 in 5 Veterans has obstructive sleep apnea. Since 2009, the number of Veterans’ claims for sleep apnea has increased by over 150%, according to USA Today.

Why do so many Veterans have sleep apnea? There are many factors during and after service that make Veterans vulnerable to this condition. There are also many service-connected conditions that can result in sleep apnea. It can also work in reverse: sleep apnea can lead to other disabilities.

Sleep apnea can be aggravated by PTSD (secondary to PTSD), also an extremely common disorder for Veterans. The same goes for depression and anxiety—or any of the 33 mental health conditions rated by the VA—which can be highly disruptive to sleep.

Traumatic brain injury and physical pain are also conditions that affect many Veterans and can lead to sleep apnea. Exposure to materials such as dust and fumes, and the resulting rhinitis or sinusitis, is also a common issue for Veterans that’s associated with sleep apnea.

What is the current VA rating for sleep apnea?

There isn’t a single rating for sleep apnea, but a range of ratings depending on the severity of your condition (as is true for other disability ratings). A disability rating at any given percentage (e.g., 30%, 50%, 100%) pays based on that percentage, no matter what condition(s) gives you that rating.

Your sleep apnea rating will compensate you based on your condition’s severity. The disability rating you’re given for sleep apnea is combined with any other disability ratings you have, if any, to give you an overall rating based on VA math.

Sleep apnea is classified by the VA as sleep apnea syndromes (diagnostic code 6847). The VA awards disability ratings for sleep apnea at the 0 percent, 30 percent, 50 percent, and 100 percent levels. The most common VA rating for sleep apnea is 50 percent.

The sleep apnea VA rating criteria are as follows:

• 100%: Chronic respiratory failure with carbon dioxide retention or cor pulmonale (a condition that causes the right side of the heart to fail), or requires tracheostomy
• 50%: Requires use of breathing assistance device such as a CPAP machine
• 30%: Persistent daytime hypersomnolence
• 0%: Asymptomatic but with documented sleep disorder breathing

If you feel groggy during the day, you may be rated at 30 percent. If you use a CPAP machine to address your sleep apnea, you’re likely to be rated at least at 50 percent. To be rated at 100 percent, you must experience chronic respiratory failure.

Can sleep apnea be service-connected?

Yes, sleep apnea can be service-connected—and will need to be service-connected in order for you to get a disability rating for sleep apnea.

Sleep apnea can be service-connected in two ways: either direct service connection or secondary service connection.

Direct service connection for sleep apnea can be difficult to obtain, as most successful cases require a diagnosis while on active duty. This would mean you had a sleep study conducted while on active duty and received a medical diagnosis of sleep apnea as a result of the study.

This is rare, because most Veterans don’t realize they have sleep apnea until after they’ve left military service. Many Veterans don’t even know what sleep apnea is while on active duty, let alone that they need a sleep study to prove they have it! For this reason, a secondary service connection for sleep apnea is much more common.

Sleep apnea and secondary service connection

A disability with a secondary service connection is a condition that was caused or made worse by an already existing service-connected condition.

If you have a service-connected disability aggravating or causing your sleep apnea, you may be eligible to get service connection for sleep apnea on a secondary basis. This is especially relevant for Veterans diagnosed with sleep apnea long after leaving the military.

With over 50 conditions that can be medically linked to sleep apnea, it’s important to understand the three elements required by law that must be satisfied in order for sleep apnea to be service-connected secondary to another service-connected disability.

1. A medical diagnosis of sleep apnea confirmed by a sleep study in VA medical records or private records
2. Evidence of a service-connected primary disability, such as musculoskeletal conditions or mental health conditions (PTSD, depression, anxiety, sinusitis, rhinitis), AND
3. A nexus (link) shown via medical evidence establishing a connection between the service-connected disability and the current disability (in this case, sleep apnea)

The three most common conditions resulting in a secondary service connection for sleep apnea and therefore a are:

• Sleep apnea secondary to PTSD or other mental health condition
• Sleep apnea secondary to a respiratory condition
• Sleep apnea secondary to medication side effects

Sleep apnea secondary to PTSD

Research shows that combat Veterans with PTSD may be at higher risk for sleep apnea than the general population. Both disorders have risk factors that affect both sleep apnea and symptoms of PTSD, and the conditions can aggravate each other.

A study conducted by the VA Healthcare System for San Diego and National Center for PTSD found that between 40 percent and 98 percent (!) of Veterans with PTSD also have a co-occuring sleep disturbance, including obstructive sleep apnea (OSA). If you’re dealing with sleep apnea as a secondary condition to PTSD, you aren’t alone!

Sleep apnea also ranks #2 on our List of the Top 5 Secondary Conditions to PTSD.

PTSD—and the side effects of medications taken to address PTSD—can lead to the development of sleep apnea in a few different ways. PTSD is well-known for causing sleep deprivation, chronic stress, and an increase in body mass or obesity due to prescribed medications. All of these can contribute to sleep apnea.

In order to prove a secondary service connection, you’ll need three things:

• A medical diagnosis of sleep apnea confirmed with a sleep study
• A service-connected PTSD disability rating (or another service-connected mental health condition)
• A medical nexus establishing a connection between your PTSD and sleep apnea

PTSD doesn’t have to be the main cause of your sleep apnea, but it does have to be connected. You can link these two by detailing the side effects of PTSD that impact your sleep apnea, with the doctor writing your nexus letter.

Also see our post on receiving a VA rating for sleep apnea secondary to PTSD.

What kind of CPAP machine does the VA use?

A Continuous Positive Airway Pressure (CPAP) machine helps treat sleep apnea by delivering a stream of air into your airways through a mask and a tube.

The VA prescribes several different types of CPAP machines. These include:

• A basic CPAP, which keeps pressure constant all night long
• A bilevel device (BiPAP), which provides two levels of pressure—more when you breathe in and less when you breathe out
• An auto-CPAP device, which changes pressure throughout the night based on your body position, sleep stage, and snoring

As you’re gathering medical evidence to file your VA claim for sleep apnea, remember that just having a CPAP alone doesn’t meet the VA’s requirements for service connection. You must have a medical statement from a doctor detailing how your sleep apnea is service-connected.

Is a CPAP machine the only treatment for sleep apnea?

Sleep apnea treatment depends on the type and severity of the condition. Before or in addition to CPAP therapy, lifestyle changes such as diet, exercise, and stress reduction may be recommended. Some Veterans with sleep apnea may experience improvement with lifestyle changes, but CPAP therapy is still among the most common treatments.

Why would a VA claim for sleep apnea be denied?

A VA claim for sleep apnea can be denied for many reasons. One common scenario is when a Veteran tries to claim sleep apnea as a primary condition when there was no diagnosis during active-duty service. Even if you have a medical diagnosis during active-duty service, without a sleep study this is difficult to claim successfully.

If you’re claiming sleep apnea as a secondary condition, make sure you already have a medical diagnosis before you make your claim. The most common reason for denial of secondary claims is not establishing a strong enough connection between the service-connected disability and the sleep apnea. Including a nexus letter for sleep apnea can be an important part of your claim to strengthen your case for a sleep apnea VA rating.

In addition, during the C&P exam for a sleep apnea VA rating, it’s important to make the case for how your sleep apnea impacts your ability to work, your daily life, and your social life.

Sleep apnea is proven to significantly reduce a person’s quality of life (in one study, the reduction in quality of life was equivalent to that observed with diabetes or hypertension). Obstructive sleep apnea can cause daytime sleepiness, snoring, depression, difficulties with concentration, and loss of memory.

Here are a few examples of how sleep apnea could be impacting your life, which you’ll want to clearly state and demonstrate in your C&P exam and in your claim:

• You have difficulty working and lose productivity during the day due to napping
• You have to use a CPAP or other breathing machine at night
• Your depression or anxiety, exacerbated by loss of sleep, affect your relationships and work
• Your inability to focus or concentrate or loss of memory affects your job or your safety

Do I need a nexus letter for sleep apnea?

We recommend a nexus letter from a medical professional to connect your condition to your military service (or secondary to a service-connected disability) in order to improve your chances of receiving a rating for sleep apnea as a secondary condition.

In our experience, a well-crafted nexus letter for sleep apnea is the single most crucial document you can provide to help prove service connection on an “at least as likely as not” basis. Having a doctor connect your sleep apnea to your secondary service-connected disability will greatly improve your chances of winning a sleep apnea VA rating.

(If you need an independent medical opinion in the VA’s language, take a look at our VA Claims Insider Elite program. Membership gives you your very own Veteran coach to walk you through the VA claim process from start to end, and access to proprietary resources. It also connects you with Vetted medical professionals in our independent referral network for medical examinations and credible medical nexus letters. It’s free to join and we don’t win unless you win.)

Can the VA take away my sleep apnea rating?

A sleep apnea VA rating can be reduced by the VA.

When you’re granted a sleep apnea VA rating, you may also be assigned a re-evaluation period (unless the condition is classified as static). Typically the re-evaluation period is anywhere from two to five years after your initial examination. At that time, the VA may schedule a re-examination to verify if your sleep apnea symptoms still exist, and if they’ve changed.

If your initial rating decision letter says that future examinations are scheduled, or you don’t have a 100% permanent and total rating, then your disability rating is not considered permanent or static by the VA.

There are cases in which your VA rating for sleep apnea would not be re-evaluated. These would include situations in which:

• Your disability is considered permanent by the VA
• Your disability is considered static by the VA
• Sleep apnea symptoms persist without material improvement for five or more years (this is known as a stabilized rating)
• You’re over age 55
• You have a continuous sleep apnea rating for 20 years or more

According to 38 CFR § 3.105(e), a rating reduction (for any condition) may only take place in cases where:

• The VA has reviewed your entire medical history
• You’ve undergoes a thorough examination
• The VA has found sustained improvement in your ability to function under the ordinary conditions of life,

The VA is also required to issue a Veteran notice of a proposed reduction and give you 60 days to submit evidence and 30 days to request a hearing (unless the reduction would not change your compensation).

Get service-connected, get compensated and get the care you need!

By covering all the bases in your sleep apnea VA claim process—having your sleep apnea diagnosed with a sleep study and connecting your sleep apnea to a service-connected condition with medical evidence—you’ll set yourself up for success to get a service-connected VA rating for sleep apnea. Also make sure to seek the care you need to get relief from the effect of sleep apnea on your health and life.

Want More Help with Your Sleep Apnea VA Claim?

At VA Claims Insider, we can help you win your claim and get the highest VA rating for sleep apnea.

At VA Claims Insider, we help Veterans understand and take control of the claims process so they can get the rating and compensation they’re owed by law. Our process takes the guesswork out of filing a VA disability claim and supports you every step of the way in building a fully-developed claim (FDC).

If you’ve filed your VA disability claim and have been denied or have received a low rating, or you’re not sure how to get started, reach out to us for a FREE VA Claim Discovery Call—so you can FINALLY get the disability rating and compensation you deserve. We’ve supported more than 15,000 Veterans to win their claims. NOW IT’S YOUR TURN.

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